Ascaris-induced acute pancreatitis

The incidence, clinical disease and outcome of acute pancreatitis caused by ascariasis in an endemic area of Kashmir, India, was studied prospectively. Ascariasis was an aetiological factor in 59 of 256 patients (23.0 per cent) with acute pancreatitis. Worms had invaded the bile duct in 51 patients, the pancreatic duct in four and both ducts in four. Pancreatitis was mild in 46 patients and severe in 13. Associated pyogenic cholangitis was present in eight. Acute complications occurred in 11 patients. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in all cases within 72 h of admission and delineated ascarides in the duodenum invading the ampullary orifice (44 patients), in the bile duct (55) and in the pancreatic duct (eight). At ERCP, worms were extracted from the ampullary orifice and removed via the mouth of 33 patients with intractable epigastric pain, leading to rapid relief of symptoms. The eight patients with pyogenic cholangitis underwent endoscopic nasobiliary drainage to decompress the bile ducts; worms were extracted from the bile duct of three of these patients using a Dormia basket. A total of 56 patients recovered from acute illness with a combination of conservative and endoscopic treatment; the other three required emergency surgery. At a mean(s.d.) follow-up of 19(7) months, ten patients showed symptomatic worm reinvasion of the biliary tree. The overall mortality rate was 3 per cent.

Intrabiliary rupture of hepatic hydatid cyst: sonographic and cholangiographic appearances

Sonographic and cholangiographic appearances of confirmed intrabiliary rupture of a hepatic hydatid cyst were studied in 15 cases. Sonographic findings included liver cyst in all cases; nonshadowing echogenic structures in the dilated biliary tree representing hydatid material, such as fragmented membranes, sand, matrix, and daughter vesicles, in eight cases; and loss of continuity of the cyst wall adjacent to the bile duct representing the site of communication in seven cases. Cholangiographic findings were as follows: filling defects of varying size and shapes in the dilated biliary tree in 13 cases, and changing shape and position of these filling defects in three of them; and leakage of contrast medium into the cyst cavity in 12 cases. Intrabiliary rupture of hepatic hydatid cyst was suggested by sonography in 10 cases (66.7%) and at cholangiography in 13 cases (86.6%). We conclude that a joint application of sonography and endoscopic cholangiography is mandatory for proper preoperative evaluation of this disorder.

COPD exacerbation rates are higher in non-smoker patients in India

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common among non-smokers exposed to solid fuel combustion at home. Different clinical characteristics in these patients may have significant therapeutic and prognostic implications.METHODS: We used medical record review and a questionnaire among COPD patients at 15 centres across India to capture data on demographic details, different types of exposures and clinical characteristics. Chest radiography and pulmonary function testing were performed in all 1984 cases; C-reactive protein and exhaled breath nitric oxide were measured wherever available.RESULTS: There were 1388 current or ex-smokers and 596 (30.0%) non-smokers who included 259 (43.5%) male and 337 (56.5%) female patients. Sputum production was significantly more common in smokers with COPD (P < 0.05). The frequency of acute symptomatic worsening, emergency visits and hospitalisation were significantly higher (P < 0.05) in non-smokers with COPD; however, intensive care unit admissions were similar in the two groups. There was no significant difference with respect to the use of bronchodilators, inhalational steroids or home nebulisation among smoker and non-smoker patients. The mean predicted forced expiratory volume in 1 sec in smokers (43.1%) was significantly lower than in non-smokers (46.5%).CONCLUSION: Non-smoker COPD, more commonly observed in women exposed to biomass fuels, was characterised by higher rate of exacerbations and higher healthcare resource utilisation.

Tigertriever in the treatment of acute ischemic stroke with underlying intracranial atherosclerotic disease

BACKGROUND

The Tigertriever device offers a unique feature that enables gradual control of the radial expansion. We sought to evaluate the safety and efficacy of the Tigertriever device in patients with large vessel occlusion (LVO) and underlying intracranial atherosclerotic disease (ICAD). The patients were part of the TIGER trial.

METHODS

The presence of underlying ICAD was determined by a core imaging laboratory using CT angiography and digital subtraction angiography. The primary outcomes included successful reperfusion, puncture to reperfusion time, and complications associated with the use of the Tigertriever device. Patients underwent mechanical thrombectomy with the Tigertriever device for up to three passes, and alternative devices were employed for subsequent passes.

RESULTS

A total of 160 patients were enrolled in the TIGER trial, and 32 patients had ICAD. Among the patients with ICAD, 78% achieved successful reperfusion within three passes of the Tigertriever device, without requiring rescue therapy. Additionally, a first pass effect was observed in 46.8%. The median time from puncture to reperfusion was 22 minutes. There were no device-related complications. The National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was significantly reduced, from an average of 17 at baseline to 8. At the 3 month follow-up, 50% of patients achieved a modified Rankin Scale score of ≤2.

CONCLUSION

Endovascular therapy (EVT) with the Tigertriever device for LVO in patients with underlying ICAD is effective and safe. When compared with historical data from other devices employed in similar cases, we observed a high rate of successful reperfusion, along with a shorter puncture to reperfusion time.

The resolute Onyx drug eluting stent for neurointervention: A technical series

INTRODUCTION

Current methods for angioplasty and stenting of the intracranial vasculature for neurointervention are limited. The Wingspan Stent System is Food and Drug Administration (FDA) approved with human device exemption for a limited patient group and despite numerous prospective registries and trials demonstrating reasonable safety, still carries warnings from the FDA for its use. Given these limitations, we present the technical nuances and outcomes of the off-label use of the Resolute Onyx drug-eluting stent (DES) for neurointerventional purposes.

METHODS

Retrospective chart review of all patients undergoing a neurointerventional procedure with the Resolute Onyx DES was done from January 2017-2021. The Resolute Onyx is a coronary balloon-mounted drug-eluting (zotarolimus) single wire laser cut stent. Technical details and procedural outcomes were collected.

RESULTS

In total 40 patients had attempted placement of the Resolute Onyx DES with procedural success in 95% of patients. The most common vessel stented was the basilar artery, 30% (12/40). The most common indication was intracranial atherosclerotic disease in 62.5% (25/40) patients, followed by acute stroke in 17.5% (7/40) of patients. The technical and procedural outcomes were excellent with only one technical complication (2.5%).

CONCLUSIONS

This series describes the initial technical safety and utility of utilizing a new generation balloon-mounted drug-eluting stent for neurointerventional purposes. This stent offers the potential for improved navigability, delivery, and outcomes compared to current neurointerventional options and warrants further study.

Mandatory Neuroendovascular Evolution: Meeting the New Demands

Background

Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients.

Summary

Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care.

Key Messages

The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

Comparative Analysis of Mechanical Thrombectomy Outcomes of Middle Cerebral Artery M1, M2 Superior, and M2 Inferior Occlusion Strokes

BACKGROUND

The M1 middle cerebral artery (MCA) commonly bifurcates into M2 superior and M2 inferior segments. However, MCA anatomy is highly variable rendering classification for mechanical thrombectomy trials difficult. This study explored safety and effectiveness of M2 MCA stroke thrombectomy stratified by M2 MCA anatomy.

METHODS

Cases of large vessel occlusion strokes treated by mechanical thrombectomy between February 2016 and August 2022 were reviewed (N = 784). M1 (n = 431) and M2 (n = 118) MCA occlusions were assessed. Among M2 MCA occlusions, only prototypical MCA bifurcation anatomy cases were included (n = 99). Dominance was assessed based on angiography. Procedural and outcome data were compared between M1, M2 superior, and M2 inferior MCA occlusions.

RESULTS

Baseline demographics and periprocedural criteria of M2 superior (n = 56) and M2 inferior (n = 43) occlusion mechanical thrombectomies were comparable. The occluded branch was dominant in 41/43 (95.3%) M2 inferior cases, but in only 37/56 (66.1%) M2 superior cases (P < 0.001). The 90-day favorable functional outcome (modified Rankin Scale score 0-2) and mortality (modified Rankin Scale score 6) rates were 60.0% and 8.9% in M2 superior, 42.9% and 32.6% in M2 inferior, and 44.1% and 26.0% in M1 (n = 431) cases. Compared with M2 superior cases, in M2 inferior cases, favorable outcome rates were lower (P = 0.094) and mortality rates were higher (P = 0.003) and resembled M1 rates (P = 0.750 and P = 0.355, respectively).

CONCLUSIONS

In the setting of prototypical MCA bifurcation anatomy, thrombectomy of dominant M2 inferior occlusions had outcome rates similar to M1 occlusions. In contrast, M2 superior occlusions had significantly lower mortality rates and a trend toward better favorable functional outcome rates.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis

BACKGROUND

Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use.

METHODS AND RESULTS

A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration.

CONCLUSIONS

Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Cerebral Ischemic Reperfusion Injury: Preventative and Therapeutic Strategies

Acute ischemic stroke is a leading cause of morbidity and mortality in the United States. Treatment goals remain focused on restoring blood flow to compromised areas. However, a major concern arises after reperfusion occurs. Cerebral ischemic reperfusion injury is defined as damage to otherwise salvageable brain tissue occurring with the reestablishment of the vascular supply to that region. The pool of eligible patients for revascularization continues to grow, especially with the recently expanded endovascular therapeutic window. Neurointensivists should understand and manage complications of successful recanalization. In this review, we examine the pathophysiology, diagnosis, and potential management strategies in cerebral ischemic reperfusion injury.

Admission hyperglycemia effect on symptomatic intracranial hemorrhage in tenecteplase versus alteplase before large vessel occlusion stroke thrombectomy

INTRODUCTION

Intravenous thrombolysis (IVT) with alteplase (TPA) in hyperglycemic stroke patients is associated with an increased risk of symptomatic intracranial hemorrhage (sICH) and poor functional outcomes. We aimed to explore the association between admission hyperglycemia and sICH in large vessel occlusion stroke (LVOS) patients treated with TNK versus TPA before endovascular thrombectomy (EVT).

METHODS

We reviewed consecutive LVOS patients treated with TPA or TNK before EVT from 01/2020 to 06/2023. EVT was performed across five comprehensive stroke centers (CSCs) in Pennsylvania. Of 569 patients, 462 met inclusion criteria: LVOS, pre-stroke modified Rankin Scale (mRS) 0-2, and last-known-well to IVT (LKW-to-IVT) ≤ 4.5 h. The rates of sICH and parenchymal hematomas (PHs) between TPA and TNK cohorts were assessed.

RESULTS

Of 462 patients, 254 (55%) received TNK, and 208 (45%) received TPA. Admission hyperglycemia (≥ 140 mg/dl) was present in 153 (33.1%) patients. Hyperglycemic patients were more frequently diabetic (p < 0.001). Admission hyperglycemia was associated with a significantly increased rate of sICH (5.9% versus 1.6%, p = 0.019) and PH (20.3% versus 11.3%, p = 0.010). Hyperglycemic patients had a significantly higher degree of overall disability as compared to normoglycemic patients (90d-mRS shift aOR 0.611, p = 0.007). Comparable rates of sICH and PH were observed in the hyperglycemic and normoglycemic cohorts among both TNK and TPA groups.

CONCLUSION

In LVOS patients receiving IVT before EVT, admission hyperglycemia significantly increased the risk of sICH and PH and was associated with worse outcomes at 90 days. No differences in sICH or PH were observed between TNK and TPA groups.

Comparison of embolic agents in preoperative embolization for intracranial meningiomas: multicenter adjusted analysis of 275 cases

BACKGROUND

Preoperative embolization has been used for intracranial meningiomas for nearly 40 years with varying preferences for embolic materials and limited comparative data on their efficacy.

METHODS

Consecutively treated patients from 2013 until 2023 who underwent preoperative embolization for meningioma from 12 centers across North America and Europe were included and classified by embolic material: (1) particles, (2) Onyx, and (3) coils. Primary outcomes included estimated blood loss (EBL), procedural complications, surgery duration, gross total resection (GTR), unplanned rescue surgery, modified Rankin Scale (mRS), and mortality. After unmatched analysis. Propensity score matching (PSM) subgroup analyses compared each pair of embolic materials, controlling for age, sex, body mass index, smoking, comorbidities, prior surgery, pre-treatment antithrombotics, WHO grade, tumor location, maximal diameter, and baseline mRS.

RESULTS

A total of 275 patients (median age 47 years, 62.9% female) underwent preoperative embolization for meningioma. The mean maximum tumor diameter was 32.9±10.1 mm, with 61.1% classified as WHO I. Onyx was most frequently used 117 (42.5%), followed by particles 107 (38.9%), and coils (18.5%). Unmatched analysis revealed that Onyx was significantly associated with reduced EBL, surgery duration, and increased GTR, while decreasing unplanned rescue surgeries compared to particles and coils. PSM produced 89, 48, and 44 matched pairs for Onyx vs. Particles, Particles vs. Coils, and Onyx vs. Coils, respectively. Onyx demonstrated significant reductions against Particles in EBL (250 mL vs. 350 mL, P = 0.011) and surgical time (291 min vs. 403 min, P < 0.001), and against Coils in EBL (250 mL vs. 400 mL, P = 0.012) and surgical time (255 min vs. 347 min, P = 0.002). Onyx also showed higher rates of gross total resection compared to Particles (80.9% vs. 56.2%, P = 0.021) and Coils (88.6% vs. 56.8%, P = 0.002). No significant differences were observed in blood transfusion requirements, embolization-related complications mRS, or mortality rates across all comparisons.

CONCLUSIONS

Onyx, a liquid embolic agent, reduces EBL which may explain the shorter surgery duration, higher GTR rates, and lower retreatment rates. Procedural risks and patient selection require further investigation.

Wallerian degeneration as a mimic of recurrence of myelitis

A middle-aged woman with idiopathic longitudinally extensive myelitis underwent repeat MR scan of cervical spine at 5-month follow-up, which showed new non-enhancing T2 hyperintensities, initially reported as myelitis recurrence. However, the hyperintensities involved both lateral corticospinal tracts caudal to the initial lesion and both dorsal columns rostral to the initial lesion and were therefore compatible with Wallerian degeneration. This radiological mimic should be considered in the differential of recurrence of myelitis.

Association between lung function and dyspnoea and its variation in the multinational Burden of Obstructive Lung Disease (BOLD) study

BACKGROUND

Dyspnoea is a common symptom of respiratory disease. However, data on its prevalence in general populations and its association with lung function are limited and are mainly from high-income countries. The aims of this study were to estimate the prevalence of dyspnoea across several world regions, and to investigate the association of dyspnoea with lung function.

METHODS

Dyspnoea was assessed, and lung function measured in 25,806 adult participants of the multinational Burden of Obstructive Lung Disease study. Dyspnoea was defined as ≥2 on the modified Medical Research Council (mMRC) dyspnoea scale. The prevalence of dyspnoea was estimated for each of the study sites and compared across countries and world regions. Multivariable logistic regression was used to assess the association of dyspnoea with lung function in each site. Results were then pooled using random-effects meta-analysis.

RESULTS

The prevalence of dyspnoea varied widely across sites without a clear geographical pattern. The mean prevalence of dyspnoea was 13.7 % (SD=8.2 %), ranging from 0 % in Mysore (India) to 28.8 % in Nampicuan-Talugtug (Philippines). Dyspnoea was strongly associated with both spirometry restriction (FVC

CONCLUSION

The prevalence of dyspnoea varies substantially across the world and is strongly associated with lung function impairment. Using the mMRC scale in epidemiological research should be discussed.

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Key Words

• Breathlessness
• Dyspnoea
• Lung function
• Spirometry

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MESH Headings

• Humans
• Dyspnea/epidemiology
• Dyspnea/physiopathology
• Dyspnea/etiology
• Male
• Female
• Middle Aged
• Prevalence
• Spirometry
• Adult
• Aged
• Vital Capacity
• Forced Expiratory Volume
• Respiratory Function Tests
• Global Health
• Lung/physiopathology
• Lung Diseases, Obstructive/physiopathology
• Lung Diseases, Obstructive/epidemiology
• Lung Diseases, Obstructive/complications
• Pulmonary Disease, Chronic Obstructive/physiopathology
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Pulmonary Disease, Chronic Obstructive/complications
• Cross-Sectional Studies

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Famous head injuries of the first aerial war: deaths of the "Knights of the Air"

World War I advanced the development of aviation from the concept of flight to the use of aircraft on the battlefield. Fighter planes advanced technologically as the war progressed. Fighter pilot aces Francesco Baracca and Manfred von Richthofen (the Red Baron) were two of the most famous pilots of this time period. These courageous fighter aces skillfully maneuvered their SPAD and Albatros planes, respectively, while battling enemies and scoring aerial victories that contributed to the course of the war. The media thrilled the public with their depictions of the heroic feats of fighter pilots such as Baracca and the Red Baron. Despite their aerial prowess, both pilots would eventually be shot down in combat. Although the accounts of their deaths are debated, it is undeniable that both were victims of traumatic head injury.

Tenecteplase versus alteplase before stroke thrombectomy: outcomes after system-wide transitions in Pennsylvania

INTRODUCTION

United States stroke systems are increasingly transitioning from alteplase (TPA) to tenecteplase (TNK). Real-world data on the safety and effectiveness of replacing TPA with TNK before large vessel occlusion (LVO) stroke endovascular treatment (EVT) are lacking.

METHODS

Four Pennsylvania stroke systems transitioned from TPA to TNK during the study period 01/2020-06/2023. LVO stroke patients who received intravenous thrombolysis with TPA or TNK before EVT were reviewed. Multivariate logistic analysis was conducted adjusting for age, sex, National Institute of Health Stroke Scale (NIHSS), occlusion site, last-known-well-to-intravenous thrombolysis time, interhospital-transfer and stroke system.

RESULTS

Of 635 patients, 309 (48.7%) received TNK and 326 (51.3%) TPA prior to EVT. The site of occlusion was the M1 middle cerebral artery (MCA) (47.7%), M2 MCA (25.4%), internal carotid artery (14.0%), tandem carotid with M1 or M2 MCA (9.8%) and basilar artery (3.1%). A favorable functional outcome (90-day mRS ≤ 2) was observed in 47.6% of TNK and 49.7% of TPA patients (p = 0.132). TNK versus TPA groups had similar rates of early recanalization (11.9% vs. 8.4%, p = 0.259), successful endovascular reperfusion (93.5% vs. 89.3%, p = 0.627), symptomatic intracranial hemorrhage (3.2% vs. 3.4%, p = 0.218) and 90-day all-cause mortality (23.1% vs. 21.5%, p = 0.491).

CONCLUSIONS

This U.S. multicenter real-world clinical experience demonstrated that switching from TPA to TNK before EVT for LVO stroke resulted in similar endovascular reperfusion, safety, and functional outcomes.

A patient with concurrent multiple sclerosis and moyamoya disease

BACKGROUND

Moyamoya disease (MMD) is a rare vasculopathy and Multiple Sclerosis (MS) is an autoimmune disease which causes CNS demyelination. While most literature has focused on misdiagnosis of MMD as an "MS-mimic", we present a patient in which both co-existed.

METHODS

Case Report RESULTS: A 57-year-old woman presented with gait dysfunction and paresthesias in both feet. MRI revealed brain and spinal cord lesions consistent with MS. Vessel imaging revealed multivessel stenosis consistent with MMD. Lumbar puncture demonstrated oligoclonal bands, leading to two diagnoses, MS and MMD.

CONCLUSIONS

MS can exist concurrently with MMD, potentially due to underlying propensity for autoimmunity.

Serial VerifyNow P2Y12 platelet reactivity units in cerebral aneurysm patients treated with ticagrelor surrounding stent-coiling or flow diversion

INTRODUCTION

Platelet function testing using serial VerifyNow P2Y12 platelet reactivity units (PRUs) is established for guiding clopidogrel antiplatelet therapy in cerebral aneurysm stenting procedures. However, for ticagrelor, the impact of serial PRU testing and the identification of safe PRU ranges remains unexplored.

METHODS

Flow diversion stenting (n = 232) and stent-assisted coiling procedures (n = 83) performed 05/2017-12/2021 were reviewed. Out of these, 31 flow diversion and 18 stent-coiling procedures were performed on 44 patients using ticagrelor. Baseline demographics, ticagrelor PRUs, and clinical outcomes were assessed.

RESULTS

Collectively, 257 ticagrelor P2Y12 PRUs were obtained. PRUs were <100 in 192/257 (74.7%) tests. Only 11/257 (4.3%) PRUs were >200. The overall median ticagrelor PRU was 38 (IQR 11-101). Among the 49 procedures, median PRUs before the procedure (25, IQR 10-67), on the day of the procedure (68, IQR 44-117), and on the day after the procedure (37, IQR 21-79) did not show the significant differences between the groups. A total of seven thromboembolic complications occurred. Median PRUs surrounding the thromboembolic complications (median 182, IQR 148-235) were significantly higher than preprocedural (p < .001), day of surgery (p < .01), and postprocedural PRUs (p < .01). All seven procedures harbored demographic, anatomic, or procedural features increasing the risk for thromboembolic complications.

DISCUSSION

The majority of periprocedural ticagrelor PRUs were <100. PRUs at the time point of thromboembolic complications were >120. Despite procedure-complicating features in each thromboembolic case, it raises the question whether safe ticagrelor PRU levels might be lower than those commonly applied for clopidogrel.

Hemodynamic outcomes of stenting for vertebrobasilar insufficiency in patients with a low flow state

INTRODUCTION

The Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study determined patients with low flow in their vertebrobasilar (VB) system are at increased risk of recurrent stroke. Endovascular interventions such as angioplasty and stenting are reserved for patients with refractory symptoms; however, few series to date have demonstrated either hemodynamic or clinical outcomes in this high-risk patient group. We present our combined institutional series of patients with symptomatic VB atherosclerotic disease and low-flow state who underwent angioplasty and stenting.

METHODS

Retrospective chart review of patients undergoing angioplasty and stenting for symptomatic VB atherosclerotic disease at two institutions was performed. Clinical and radiographical outcomes were collected including flow rates using quantitative MRA (QMRA) pre- and post-stenting.

RESULTS

Seventeen patients underwent angioplasty and stenting for symptomatic VB atherosclerotic disease and met VERiTAS low-flow state criteria. There were four cases (23.5%) of periprocedural stroke, two of which were minor and transient. The stent was placed intracranially in 82.4% of patients. Basilar and bilateral posterior cerebral artery (PCA) flows significantly improved post-stenting (p < 0.05) and normalized based upon VERiTAS criteria in all patients. Fourteen patients had delayed QMRA at mean follow-up 20 months demonstrating appropriate patency and flow post-stenting. Two patients (10%) had recurrent stroke, one from medication nonadherence and in-stent thrombosis, and the other from a procedural dissection that subsequently became symptomatic.

CONCLUSIONS

Our series demonstrates angioplasty and stenting significantly improve intracranial flow over long-term. Angioplasty and stenting may improve the natural history of low-flow VB atherosclerotic disease.