Supplementingand activating blood circulation method to treat vertebrobasilar dolichoectasia with posterior circulatory watershed infarction: a case report of two patients

Vertebrobasilar dolichoectasia (VBD), a rare posterior circulation vascular variant disease, is an important risk factor for many acute cerebrovascular diseases. An insufficient understanding of VBD often leads to misdiagnose. Two cases of VBD that were initially diagnosed as posterior circulation watershed infarction are reported here. Absence of common causes of stroke including hypoperfusion, blood system diseases, carotid and aortic dissection, and eosinophil elevation, the symptoms of the 2 patients met the diagnostic criteria of VBD. Both patients displayed symptoms that were in line with the Traditional Chinese Medicine (TCM) syndrome pattern of "deficiency and blood stasis". Accordingly, they were comprehensively treated with Supplementingand activating blood circulation method. The clinical manifestations of the 2 patients were remarkably improved and no recurrence of watershed infarction was found in a 1-year follow-up. A detailed medical history and laboratory examination are capable of improving diagnostic accuracy of VBD. TCM treatment based on syndrome identification might be a promising candidate for VBD management.

CT chest-cerebral angiography for basilar artery occlusion caused by pulmonary arteriovenous malformation

Early diagnosis of basilar artery occlusion (BAO) based only on clinical findings is challenging. We present a fully recovered case of BAO caused by pulmonary arteriovenous malformation (PAVM) that was diagnosed early using a protocol for CT angiography (CTA) and promptly treated with endovascular therapy (EVT). A woman in her 50s complained of vertigo with normal level of consciousness (LOC). On arrival, her LOC decreased to a Grass Coma Scale score of 12, and we performed a CT chest-cerebral angiography protocol. Head CTA showed BAO, and an intravenous tissue plasminogen activator was administered, followed by EVT. Chest contrast-enhanced CT showed PAVM in segment 10 of the left lung, which was treated with coil embolisation. For patients with a complaint of vertigo, BAO should be suspected, even if they have an initially normal LOC. A CT chest-cerebral angiography protocol is useful for prompt diagnosis and treatment of BAO and can reveal undetermined causes.

Symptomatic vertebrobasilar artery stenosis treated with enoxaparin

Nil.

Reversible cerebral vasoconstriction syndrome with basilar artery stenosis: A case report

INTRODUCTION

Acute severe headaches in young patients may be associated with fatal neurological complications that necessitate imaging examinations. Among acute severe headaches, a thunderclap headache may indicate the rupture of a cerebral aneurysm or the onset of reversible cerebral vasoconstriction syndrome for which emergent evaluation is required.

PATIENT CONCERNS

We report the case of a 36-year-old man who presented to our hospital with an acute severe headache after excessive exercise the previous day. He was prescribed a pain reliever and discharged under the suspicion of vestibular migraine but returned to the emergency room after 4 hours due to right hemiparesis, right facial palsy, severe dysarthria, and a mild drowsy mental status.

DIAGNOSIS

After cerebral angiography, we diagnosed basilar artery stenosis with acute infarction in the posterior circulation due to reversible cerebral vasoconstriction syndrome.

INTERVENTIONS

Brain computed tomography angiography revealed complete occlusion of the vertebrobasilar artery. Transfemoral cerebral angiography showed spontaneous improvement in the occlusion before thrombectomy.

OUTCOMES

Ten months later, high-resolution vessel wall magnetic resonance angiography showed persisting severe stenosis of the basilar artery.

CONCLUSIONS

A headache in young patients with risk factors of atherosclerosis, such as smoking history, uncontrolled hypertension, and dyslipidemia may be caused by reversible cerebral vasoconstriction syndrome or ischemic stroke, which has fatal neurological complications. Therefore, reversible cerebral vasoconstriction syndrome or ischemic stroke should be suspected and appropriately evaluated in such patients, even if the headache is not the thunderclap type.

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.

Polyethylene glycol-conjugated human adrenomedullin as a possible treatment for vascular dementia

Adrenomedullin (AM) is a multifunctional bioactive peptide. Recent studies have shown that AM has protective effects against ischemic brain damage. We recently prepared a long-acting human AM derivative that was conjugated with a 60 kDa polyethylene glycol (PEG-AM), which had an effect similar to that of native AM. In this study, we examined the effect of PEG-AM on four-vessel occlusion model rats, which exhibit vascular dementia. From day 10 to day 14 after surgery, the learning and memory abilities of the rats were examined using a Morris water maze. The rats were treated with a single subcutaneous injection of 1.0 or 10.0 nmol/kg of PEG-AM. PEG-AM treatment reduced the escape latency in the hidden platform test. Furthermore, the treatment increased the time spent in the platform quadrant in the probe test. The data showed that PEG-AM injection prevented memory loss and learning disorders in dose-dependent manner. On day 14, the immunoreactive AM concentration in plasma was 9.749 ± 2.167 pM in the high-dose group (10.0 nmol/kg) and 0.334 ± 0.073 pM in the low-dose group (1.0 nmol/kg). However, even in the low-dose group, a significant effect was observed in both tests. The present data indicate that PEG-AM is a possible therapeutic agent for the treatment of ischemic brain injury or vascular dementia.

Extracranial-to-Intracranial Bypass for Refractory Vertebrobasilar Insufficiency

BACKGROUND

Vertebrobasilar insufficiency (VBI) is associated with high rates of morbidity and mortality, especially after failure of first-line medical and/or endovascular therapies. Although the optimal therapeutic strategy for refractory VBI remains unclear, surgical bypass represents a potentially life-saving treatment in this patient subset.

METHODS

A multi-institution retrospective database review was performed to identify patients with symptomatic refractory VBI over a 4-year period (July 2014 to July 2018). Surgical treatments, as well as clinical and neurologic outcomes were recorded.

RESULTS

Five patients were identified with refractory VBI (average age 55 ± 11.0 years). All 5 patients had clinically significant posterior circulation strokes on presentation. Three patients underwent superficial temporal artery-to-superior cerebellar artery bypass based on significant acute perfusion mismatches or progressive strokes despite maximal medical therapy; 1 surgical patient (33%) experienced punctate perioperative strokes and there were no significant bypass related complications. Functional outcomes in the 3 surgical patients were correlated with preoperative stroke burden. The remaining 2 patients experienced rapid neurologic declines after presentation that precluded bypass, and died shortly thereafter.

CONCLUSIONS

Refractory VBI has high morbidity, with cerebral bypass representing a safe and potentially efficacious treatment for selected patients. Long-term post-bypass outcomes are dependent on the level of irreversible preoperative neurologic injuries.

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.

[Clinical efficacy of reconstructive operations on the third (V3) segment of the vertebral artery]

Presented herein are the results of a prospective cohort study of clinical efficacy of medicamentous treatment and operations of shunting to the third segment (V3) of the vertebral artery in patients with vertebrobasilar insufficiency (VBI). The study included a total of 60 patients with pronounced clinical manifestations of VBI and concomitant lesions of the V1 and V2 segments of the vertebral arteries. The patients were found to have no significant involvement of the carotid bifurcation. At the first stage, all patients during 12 months were receiving a course of optimal medicamentous therapy. Clinical improvement was observed in only 3 (5%) patients, and they were not subjected to surgery. The remaining 57 patients with no improvement after the course of conservative therapy underwent a second-stage treatment consisting in shunting to the third (V3) segment of the vertebral artery. Of these, 5 patients underwent arterial bypass grafting and 52 patients endured autovenous shunting. In the early postoperative period one patient developed thrombosis of the autovenous shunt. This patient died of repeat stroke into the trunk of the brain. In 56 patients the shunts were patent. Clinical improvement was observed in all 56 patients during 3-month follow-up. By month 12, all 5 patients with autoarterial shunts developed shunt thrombosis and were found to have a return of the clinical course of VBI, with no events of either acute impairment of cerebral circulation or transitory ischaemic attacks. We managed to mitigate the clinical course of VBI in 51 (85%) patients with autovenous shunts, with this effect persisting for 12 months and more after the operation. The differences between the results of medicamentous and surgical treatment were statistically significant (p≤0.01). During 3 years of follow up the achieved improvement persisted in 88.7% of the surgically treated patients and during 7 years in 78.3% of patients, with the 3- and 7-year shunt patency rate amounting to 90.2 and 88.2%, respectively.

Effect of statin on progression of symptomatic basilar artery stenosis and subsequent ischemic stroke

Background and objective

Symptomatic basilar artery stenosis (BAS) is associated with high risk of ischemic stroke recurrence. We aimed to investigate whether statin therapy might prevent the progression of symptomatic BAS and stroke recurrence.

Methods

We retrospectively analyzed the data of patients with acute ischemia with symptomatic BAS, which was assessed using magnetic resonance angiogram (MRA) imaging on admission day, and 1 year later (or the day of the clinical event). The clinical endpoints were recurrent ischemic stroke and its composites, transient ischemic attack, coronary disease, and vascular death.

Results

Of the 153 patients with symptomatic BAS, 114 (74.5%) were treated with a statin after experiencing a stroke. Statin therapy significantly prevented the progression of symptomatic BAS (7.0% vs 28.2%) and induced regression (22.8% vs 15.4%) compared to non-statin users (p = 0.002). There were 31 ischemic stroke incidences and 38 composite vascular events. Statin users showed significantly lower stroke recurrence (14.9% vs 35.9%, p = 0.05) and composite vascular events (17.5% vs 46.2%; odds ratio [OR], 0.29; 95% confidence interval [CI], 0.13–0.64) than those not using statins did. Recurrent stroke in the basilar territory and composite vascular events were more common in patients with progression of BAS than they were in other patients (OR, 5.16; 95% CI, 1.63–16.25 vs OR, 4.2; 95% CI, 1.56–11.34).

Conclusion

Our study suggests that statin therapy may prevent the progression of symptomatic BAS and decrease the risk of subsequent ischemic stroke. Large randomized trials are needed to confirm this result.

Protective effect of the microcatheter placed at the normal vertebral artery in intracranial stent-assisted angioplasty for vertebral artery stenosis: A case report

RATIONALE

A carefully designed intracranial stent-assisted angioplasty (SAA) is presented here that may prevent subsequent branch artery occlusion.

PATIENT CONCERNS

A 72-year-old man with a 3-month history of progressive and intermittent vertigo without any obvious trigger, accompanied by nausea.

DIAGNOSES

Intracranial atherosclerotic disease.

INTERVENTIONS

the patient underwent intracranial SAA in accordance with the procedure described here.

OUTCOMES

The patient's paroxysmal vertigo completely subsided, with no complications during the short-term follow-up.

LESSONS

This novel intracranial SAA procedure is safe and may reduce the risk of subsequent artery occlusion.

[Pathogenesis of the vascular consequences caused by cervical instability and their algorithm for pharmacotherapy]

256 patients with radiologic detected cervical instability were examined. This pathology may be the cause of arterial or venous vertebra-basilar disorders. We realized extensive examination the patients with the cervical instability for the pathogenic correction of vascular consequences. We founded normal blood flow only in 19.9% cases without morphology alterations the vessels of both basins. 80.1% patients had different cerebral hemodynamic disorders variations. According to our examination plan we detected the vertebra-basilar insufficiency pathogenesis and proposed medicinal correction of the cerebral instability consequences.

Clinical research of persimmon leaf extract and ginkgo biloba extract in the treatment of vertebrobasilar insufficiency

This paper aims to compare the curative effects of persimmon leaf extract and ginkgo biloba extract in the treatment of headache and dizziness caused by vertebrobasilar insufficiency. Sixty patients were observed, who underwent therapy with persimmon leaf extract and ginkgo biloba extract based on the treatment of nimodipine and aspirin. After 30 days, 30 patients treated with persimmon leaf extract and 30 patients with ginkgo biloba extract were examined for changes in hemodynamic indexes and symptoms, such as headache and dizziness. The results showed statistically significant differences of 88.3% for the persimmon leaf extract and 73.1% for the ginkgo biloba extract, P < 0.05. Compared to the group of ginkgo biloba extract, the group of persimmon leaf extract had more apparent improvement in the whole blood viscosity, plasma viscosity, fibrinogen, hematokrit, and platelet adhesion rate, and the difference was statistically significant (P < 0.05 or P < 0.01). Based on these analyses, it can be concluded that persimmon leaf extract is better than ginkgo biloba extract in many aspects, such as cerebral circulation improvement, cerebral vascular expansion, hypercoagulable state lowering and vertebrobasilar insufficiency-induced headache and dizziness relief.

Monitoring and imaging the clot during systemic thrombolysis in stroke patients

Intravenous thrombolysis is the only approved treatment for acute ischemic stroke when administered within the first 3 h of stroke onset. Response to systemic thrombolysis depends on several factors including the location of arterial occlusion, clot characteristics and, ultimately, the embolic source. In the last few years, tremendous progress has been made, resulting in the widespread implementation of noninvasive neurovascular techniques. These imaging modalities are being increasingly performed in the acute stroke setting, without substantial delay, in a large number of centers worldwide. Transcranial Doppler ultrasound provides a unique opportunity to assess several aspects of clot dissolution by means of continuous monitoring of recanalization during and after tissue plasminogen activator administration. This approach allows for the evaluation of patients at the bedside and in real time due to the commencement, timing, speed and degree of artery reopening in addition to allowing the documentation of reocclusion after successful recanalization. Gradient refocused echo susceptibility vessel sign (GRE SVS) magnetic resonance imaging may be particularly useful for the identification of an intravascular thrombus during the acute phase of ischemic stroke; GRE SVS may represent a surrogate of clot composition and differential response to thrombolysis. The increasing availability of advanced neurovascular techniques may, in the near future, improve the design of stroke trials. The capability of these techniques to assess not only tissue viability but also key aspects regarding susceptibility to thrombolysis such as location, amount, composition, and age of the offending clot may improve the safety and efficacy profile of thrombolytic therapy for acute ischemic stroke.

Vertebral artery injuries following cervical spine trauma: a prospective observational study

PURPOSE

The purpose of this study was to report on the incidence, diagnosis and clinical manifestation of VAI following cervical spine injuries observed in a prospective observational study with a standardized clinical and radiographical protocol.

METHODS

During a 16-year period, 69 (mean age: 43 ± 20.7 years; 25 female, 44 male) of 599 patients had cervical spine injury suspicious for VAI due to facet luxation and/or fractures extending into the transverse foramen. Diagnosis and management of these patients followed a previously published protocol (Kral in Zentralbl Neurochir 63:153-158, 2002). Digital subtraction angiography (DSA) was performed in all 69 patients. Injury grading of VAI was done according to Biffl et al. (Ann Surg 231:672-681, 2000). All patients with VAI were treated with anticoagulation (heparin followed by ASS) for 6 months.

RESULTS

In cases suspicious for VAI, the incidence of VAI detected by DSA was 27.5% (n = 19 of 69 patients). VAI Grade I occurred in 15.8%, Grade II in 26.3%, Grade IV in 52.6% and Grade V in 5.2%. Of 19 patients, 4 (21%) had clinical signs of vertebrobasilar ischemia. Two patients died in hospital after 4 and 21 days respectively. Of 69 patients, 33 (47.8%) with suspected VAI had unstable spine injuries and were treated surgically.

CONCLUSION

In patients with cervical spine fractures or dislocations crossing the course of the vertebral artery, VAI are relatively frequent and may be associated with significant morbidity and mortality. VAI were identified by DSA in 27.5%. Despite anticoagulation therapy, 5.8% became clinically symptomatic and 2.9% died due to cerebrovascular ischemia.

[Efficacy of cytoflavin in the treatment of vertebrobasilar insufficiency]

Neurology symptoms and Doppler figures before and after cytoflavin course therapy have been studied in a group of 52 patients with chronical insufficiency of cerebral blood circulation mostly in the vertebrîbasilar vessel region. Cytoflavin infusions reliably reduced neurologic disorder symptoms, improved cerebrovascular reaction, and extended compensation possibilities of blood circulation in the vertebrobasilar region. The results of investigation proved the efficacy, safety and good tolerance of cytoflavin in patients.

The effect of the sildenafil citrate on cerebral vasospasm and apoptosis following experimental subarachnoid hemorrhage in rats

AIM

The therapeutic effect of sildenafil citrate on cerebral vasospasm after experimental subarachnoid hemorrhage (SAH) was studied in a rat model.

METHODS

We used four groups of seven rats were as follows: no SAH, no treatment; SAH only; SAH plus 2 days of peroral sildenafil citrate 5mg/kg treatment and SAH plus 2 days of peroral sildenafil citrate 15 mg/kg treatment. Three different parameters were evaluated including the diameter of the basilar artery, the level of lipid peroxidation and the degree of the apoptosis 48 hours following SAH.

RESULTS

The results showed that sildenafil citrate attenuated SAH-induced cerebral vasospasm in the treatment groups in terms of the diameter of the basilar artery and lipid peroxidation in the two treatment groups, but there was no difference in terms of the level of apoptosis.

CONCLUSION

This study indicates that further research on the therapeutic effect of sildenafil citrate can be combined with the use of any apoptosis-blocking agent for the treatment of cerebral vasospasm following experimental subarachnoid hemorrhage.

Unusual cause of acute neurologic deficit in childhood: primary central nervous system vasculitis presenting with basilar arterial occlusion

INTRODUCTION

Primary central nervous system (CNS) vasculitis of childhood is a rare disorder. The most common signs and symptoms are acute severe headache and focal neurologic deficit. It should be suspected in children who have an acquired neurologic deficit that remains unexplained after an initial basic evaluation. Diagnosis usually depends on brain magnetic resonance imaging and conventional angiography of cerebral vasculature. Stenosis is the most common angiographic finding and it usually affects the middle cerebral artery and its branches. Anterior and posterior circulation is rarely involved.

CASE REPORT

In this report, we describe an 8-year-old boy who presented with vertebrobasilar insufficiency symptoms and primary CNS vasculitis diagnosis was made later.

[Omaron in the treatment of vertebrobasilar insufficiency]

The study aimed at evaluation of tolerability, safety and clinical efficacy of omaron in the treatment of vertebrobasilar insufficiency (VBI). Forty patients with different stages of VBI have been examined. A diagnosis of VBI was based on the results of neurological study, ultrasonic dopplerography, electroencephalography, electrocardiography, brain MRI and CT examination. Neurological scales were used for assessment of neurological status and further data processing. The treatment with omaron resulted in significant clinical improvement and stabilization of the pathological process. The drug is well-tolerated by patients including those of older age groups.

Food-dependent exercise-induced anaphylaxis induced by low dose aspirin therapy

BACKGROUND

Food-dependent exercise-induced anaphylaxis (FDEIA) is a distinct form of common food allergy characteristically induced by a combination of causative food ingestion and physical exercise. Recent investigations have documented that aspirin consumption, in place of exercise, also induces allergic symptoms.

CASE SUMMARY

A 63-year-old man began low dose aspirin therapy on September 2005. Since January 2006, he had repeated episodes of generalized urticaria and lost consciousness while he was exercising after eating wheat. He was strongly positive for omega-5 gliadin in a cap-system fluorescent enzyme immunoassay. Therefore, a diagnosis of wheat-dependent exercise-induced anaphylaxis was made.

DISCUSSION

Patients with aspirin-provoked FDEIA have been reported previously as taking ordinary doses of aspirin for reducing pain, inflammation and fever. However, in our patient, low dose aspirin therapy for reducing cardiovascular risk possibility induced FDEIA. Growing numbers of elderly people take low doses of aspirin for prevention of cerebral or myocardial infarction. Therefore, physicians should remember that aspirin consumption, even at low doses, is a risk factor for FDEIA.

Treatment of vertebrobasilar insufficiency--associated vertigo with a fixed combination of cinnarizine and dimenhydrinate

Thirty-seven patients suffering from vertigo associated with vertebrobasilar insufficiency participated in our prospective, single-center, double-blind, comparative study. Patients were randomly allocated to treatment with placebo; betahistine (12 mg betahistine dimesylate, one tablet three times daily); or the fixed combination of 20 mg cinnarizine and 40 mg dimenhydrinate (one tablet three times daily) for 4 weeks. The primary efficacy end point was the decrease of the mean vertigo score (S(M)), which was based on the patients' assessments of 12 individual vertigo symptoms after 4 weeks of treatment. Patients treated with the fixed combination showed significantly greater reductions of S(M) as compared to patients receiving placebo (p < .001) or the reference therapy betahistine (p < .01). The vestibulospinal parameter lateral sway (Unterberger's test) improved to a significantly greater extent in patients taking the fixed combination as compared to those receiving placebo (p < .001). No serious adverse event was reported in any therapy group. The tolerability of the fixed combination was judged as very good or good by 91% (betahistine, 73%; placebo, 82%). In conclusion, the fixed combination proved to be statistically more effective than the common antivertiginous drug betahistine in reducing vertebrobasilar insufficiency-associated vertigo symptoms.

Timing of recanalization after microbubble-enhanced intravenous thrombolysis in basilar artery occlusion

BACKGROUND AND PURPOSE

Information about early recanalization of basilar artery occlusion after systemic tissue plasminogen activator remains unknown. We aimed to determine the timing of recanalization in basilar artery occlusion treated with systemic thrombolysis, microbubbles, and continuous transcranial Doppler monitoring.

METHODS

We studied 20 patients with <12 hours basilar artery occlusion treated with intravenous tissue plasminogen activator, 2 hours continuous ultrasound, and 3 boluses of microbubbles. Transcranial Doppler assessed recanalization at different time points. Outcome was assessed using the National Institutes of Health Stroke Scale and modified Rankin scale. Patients were considered to be independent if modified Rankin scale score was <3 at 90 days.

RESULTS

Median admission National Institutes of Health Stroke Scale was 18.5 (interquartile range 16 to 26.5) and median time to treatment was 180 minutes (range, 80 to 720 minutes). Rate of complete recanalization raised progressively: at 1 hour 10%, at 2 hours 20%, at 6 hours 35%, and at 24 hours 50%. In 10 patients (50%), no recanalization was observed at 24 hours. Median discharge National Institutes of Health Stroke Scale was 14 (interquartile range 1 to 30). Degree of National Institutes of Health Stroke Scale improvement was related to time of recanalization: median discharge National Institutes of Health Stroke Scale--1 for recanalization between 0 and 6 hours, 11 for recanalization between 6 and 24 hours, and 30 if no recanalization occurred (P=0.002). At 3 months, mortality was 35%. Only one patient (10%) who recanalized within 24 hours died as compared with 60% of nonrecanalizers (P=0.029). Rate of independent patients progressively decreased as time to recanalization increased (P=0.006).

CONCLUSIONS

In acute basilar artery occlusion, endovenous tissue plasminogen activator, microbubbles, and continuous ultrasound leads to early recanalization in a significant number of patients and this is associated with favorable outcome. Immediate intravenous tissue plasminogen activator treatment should be the first therapeutic option in these patients.

Intra-arterial thrombolytic therapy for acute basilar occlusion: pro

Acute thromboembolic occlusion of the basilar artery accounts for 6% to 10% of large-vessel stroke in humans. Because of the brain region supplied by this artery, the case fatality rate is the highest for all ischemic stroke subtypes, ranging from 40% to 86%. Patients who undergo successful recanalization of the basilar artery by intra-arterial thrombolysis have lower mortality of approximately 39%. Considering all published series, a consistent survival benefit is predicted by revascularization (mortality 87% nonrecanalized compared with 39% recanalized; P<0.001). Although no large randomized studies of revascularization for acute basilar artery occlusion have been performed, it is unlikely that endovascular efforts are inferior to the natural history of the disease, and it is likely that patients benefit from this aggressive approach.

Long-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared with medical treatment in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial

BACKGROUND AND PURPOSE

The long-term outcome of endovascular intervention compared with best medical management of patients with symptomatic vertebral artery stenosis is uncertain. We therefore compared these treatments in a randomized trial with long-term follow-up.

METHODS

In the international, multicenter Carotid And Vertebral Artery Transluminal Angioplasty Study, 16 patients with symptomatic vertebral artery stenosis were randomized in equal proportions to receive endovascular therapy (balloon angioplasty or stenting) or best medical treatment alone. An independent neurologist followed up the patients for as long as 8 years.

RESULTS

Endovascular intervention was technically successful in all 8 patients, but 2 patients experienced transient ischemic attack at the time of endovascular treatment. There were no deaths or strokes in any arterial territory within the first 30 days. During a mean follow-up period of 4.7 years, no patient in either treatment group experienced a vertebrobasilar territory stroke, but 3 patients in each treatment arm died of myocardial infarction or carotid territory stroke, and 1 endovascular patient had a nonfatal carotid territory stroke.

CONCLUSIONS

Patients with vertebral artery stenosis were more likely to have carotid territory stroke and myocardial infarction during follow-up than have recurrent vertebrobasilar stroke. The trial failed to show a benefit of endovascular treatment of vertebral artery stenosis, but the numbers of patients included was small. Larger randomized trials are required to determine whether vertebral artery stenting is justified in patients at higher risk of vertebrobasilar stroke. Treatment of patients with vertebral artery stenosis should focus on global reduction of vascular risk, including prevention of carotid territory stroke and myocardial infarction.

[Management of elderly patients with symptomatic vertebrobasilar insufficiency]

OBJECTIVE

To evaluate the feasibility, safety and short-term efficacy of stent-assisted angioplasty and/or drug therapy for elderly patients with symptomatic vertebrobasilar insufficiency.

METHODS

Elderly patients (> or = 60 years old) with symptomatic vertebrobasilar stenosis (> or = 50%) demonstrated by cerebral angiography were treated with drug therapy and some with endovascular stenting further from April 2001 to June 2006. The clinical, imaging, intervention and follow-up data were collected and analyzed.

RESULTS

Eighty-one elderly patients were chosen for study, including 68 males and 13 females. The mean age is 70 years (60 - 87 years); stroke rate of 4.9% (4/81) and stroke-related mortality rate of 2.5% (2/81) were found in this group during hospitalization and follow-up (mean 28.1 months), and symptoms resolved or improved clinically in 66 (81.5%). Fifty-two balloon expandable stents were placed in 48 (59.3%) patients of this group with a technical success rate of 98.1% and the mean degree of stenosis was reduced from (82.4 +/- 13.1)% to (6.4 +/- 3.2)% (t = 22.4, P = 0.00).

CONCLUSIONS

Appropriate management including endovascular stenting and/or drug therapy may improve short-term outcomes of elderly patients with symptomatic vertebrobasilar insufficiency; meanwhile, stent-assisted angioplasty is technically feasible and relatively safe.

Ischemic and hemorrhagic complications after intra-arterial fibrinolysis in vertebrobasilar occlusion

BACKGROUND AND PURPOSE

To evaluate the incidence and location of hemorrhagic and ischemic lesions after local intra-arterial (IA) fibrinolysis in patients with acute vertebrobasilar occlusion (VBO).

METHODS

One hundred forty-three patients with VBO treated with local IA fibrinolysis were retrospectively evaluated. Two different thrombolytic substances, namely urokinase (UK, n = 57 patients) and recombinant tissue plasminogen activator (rtPA, n = 86 patients), were used. Incidence and location of intracranial hemorrhage and ischemic infarction were assessed by means of 403 peri-interventional CT and MR imaging scans. Recanalization success and bleeding rate were correlated with the type and dosage of fibrinolytic agent. Multiple logistic regression was used for statistical analysis.

RESULTS

Intracranial hemorrhage was detected in 46 (32%) patients. Bleeding rate was significantly higher for high-dose rtPA than for UK (36% versus 21%, P < .01). Neurologic outcome was worse in patients with postinterventional bleeding (P < .001). Ischemic infarctions were present in 136 (95%) patients. Ischemic lesions of the occipital lobe and thalamus were more frequently seen in the case of successful recanalization than after absent recanalization (P < .005). Occlusion of the postcommunicating segment of the posterior cerebral artery after successful recanalization was seen in 39% of patients.

CONCLUSIONS

In acute VBO, bleeding rate after IA rtPA seems to be higher than that using IA UK, especially after high-dose rtPA. Ischemic lesion patterns after successful local IA fibrinolysis are common and correspond to the frequent distal migration of the thrombus. Novel recanalization techniques allowing for endovascular thrombectomy are needed to reduce ischemic and hemorrhagic complications in the treatment of acute VBO.

[Cerebrolysin treatment of mild cognitive impairment of vascular genesis]

AIM

To evaluate effects of cerebrolysin on cognitive functions in patients with mild cognitive impairment of vascular genesis.

MATERIAL AND METHODS

The examination covered 43 patients aged 40 to 80 years with mild cognitive impairment. We used Tinetti scale for assessment of dynamics in postural disorders; neuropsychological examination was based on Short Scale of Psychic Status Assessment, Mattis Dementia Scale, ADAS- Cog scale, digit test and other tests. Cerebrolysin was injected in drops intravenously in a dose 10 ml per 200 ml of the physiological solution. The course included 20 injections with immediate assessment of the response and 3 months after the course.

RESULTS

Cerebrolysin improved motor activity, memory, attention, general cognitive status. The effect is delayed and was noticeable 3 months after the end of the treatment course. Side effects were absent.

CONCLUSION

Cerebrolysin influences neurodynamic aspects of mnestic and cognitive activity associated with frontal-subcortical relations that also results in motor activity improvement.

Massive pontine hemorrhagic transformation associated with an anticoagulant for basilar artery occlusion

Symptomatic hemorrhagic transformation is common in supratentorial and cerebellar infarction, but is rare in brainstem infarction. It is seldom reported in basilar artery occlusion. Although early arterial recanalization by thrombolytic agent has became the new trend of treatment, for some neurologists anticoagulant is still a conventional alternative treatment of basilar artery occlusion, especially in longer-existing ischemic deficits. We report a case of massive pontine hemorrhage associated with enoxaparin (low-molecular-weight heparin) treatment for basilar artery occlusion. On the basis of the clinical information and neuroimaging, an embolism was the most likely cause of stroke. The case presented herein adds massive pontine hemorrhagic transformation to the list of possible complications of anticoagulants for basilar artery occlusion. Apart from no evidence-based benefit in treatment of basilar artery occlusion, anticoagulant may contribute to devastating hemorrhagic transformation.

[Clinical observation on Qingling Dingxuan Decoction in treating vertigo cause by insufficient blood-supply of ventebrobasilar artery]

OBJECTIVE

To observe the therapeutic effect of Qingling Dingxuan Decoction (QDD) on vertigo caused by insufficient blood-supply of ventebrobasilar artery (IBVA).

METHODS

Thirty-nine patients were divided into the flunarizine group (n=19) and the QDD group (n=20) treated with respective medicine on the base of routine treatment with Chinese and Western medicine. The clinical efficacy and recurrent rate were observed and compared.

RESULTS

Compared with those in the flunarizine group, clinical curative effect was better, recurrent rate lower, symptom score higher, hemorheological parameters and transcranial doppler indexes were improved more significant in the QDD group (P < 0.01 or P < 0.05).

CONCLUSION

QDD had obvious therapeutic effect on IBVA. Improvement of microcirculation and reduction of blood viscosity may be one of the therapeutical mechanisms.

Outcome of acute vertebrobasilar occlusions treated with intra-arterial fibrinolysis in 180 patients

BACKGROUND AND PURPOSE

To evaluate predictors of recanalization and a favorable neurologic outcome in patients with acute vertebrobasilar occlusion (VBO) treated with local intra-arterial fibrinolysis (LIF).

METHODS

The multicentric data of 180 patients with acute VBO treated with LIF were retrospectively evaluated. The modified Rankin scale (mRS) was used to evaluate the neurologic status before LIF and at the time of discharge. Patient's sex, age, etiology of VBO, recanalization, symptom duration before LIF, and pretreatment mRS were correlated with posttreatment mRS. Multiple logistic regression analysis was used to identify independent variables for recanalization and neurologic outcome.

RESULTS

The overall mortality was 43%. Complete recanalization was achieved in 99 (55%) patients and a partial recanalization in 35 (19%) patients, respectively. Recanalization was significantly associated with a favorable outcome (P < .001). The success of recanalization was negatively correlated with the volume of the thrombus (P < .001). No correlation was found between site and etiology of VBO and recanalization. Neurologic outcome correlated strongly with the pretreatment mRS (P < .001) and also with age (P < .02). Coma lasting less than 4.5 hours led to a positive trend toward a better outcome after univariate testing (P < .001).

CONCLUSIONS

Success of recanalization and neurologic status before treatment predict neurologic outcome in patients with VBO. Thrombus volume has an adverse effect on the recanalization success.

[Idiopathic thunderclap headache: reversible vasospasm of the Arteria basilaris]

Thunderclap headache describes a rare headache syndrome characterized by abrupt-onset severe headache mimicking subarachnoidal bleeding, which has to be excluded by adequate diagnostic procedures such as digital subtraction angiography. The pathophysiology is still not clear but there are an increasing number of reports which describe some kind of vasospasm of the intracranial arteries during the headache episode. Here we describe a patient with a thunderclap headache and a mid-basilar narrowing due to a reversible vasospasm.

Recovery in a patient with locked-in syndrome

BACKGROUND AND PURPOSE

Sildenafil citrate has been shown to enhance neurogenesis, angiogenesis, synaptogenesis, and neurological outcome by augmentation of cyclic guanosine monophosphate (cGMP) levels in animal models of ischemic stroke. Whether sildenafil citrate may be helpful for recovery in human stroke is unknown at this time.

METHODS

A 41-year-old woman with locked-in syndrome due to pontine infarction began receiving 150 mg of oral sildenafil citrate daily on a compassionate use basis in August 2003 and continues treatment at this time. Magneto-encephalography (MEG) was performed at 12 and 17 months after stroke.

RESULTS

No serious adverse events have occurred. Significant milestone recoveries including standing, use of both arms, talking, and full return of swallowing have occurred, particularly after nine months of treatment. The MEG showed a significantly increased amplitude in the somatosensory cortex.

CONCLUSION

Daily use of high dose sildenafil citrate appears to be safe in this patient with stroke resulting in locked-in syndrome. Further studies will be required to establish safety and efficacy.

Treatment of ischemic stroke complicating cardiac catheterization with systemic thrombolytic therapy

Ischemic stroke is a rare but serious complication of cardiac catheterization. We report a case in which systemic thrombolytic therapy was successfully utilized in treating a patient with a cerebellar stroke, leading to obtundation during elective cardiac catheterization. Underlying bilateral vertebrobasilar disease with thrombotic embolization to the basilar artery was postulated to be the pathophysiological basis for the stroke and subsequent success of thrombolytic treatment in this patient. As the consequences of this rare complication are severe, systemic thrombolytic therapy should be considered for patients suffering an acute ischemic stroke during cardiac catheterization or percutaneous coronary intervention.

Skew deviation: a precursor to basilar artery thrombosis

The aim of this study was to describe skew deviation and vertical nystagmus as the initial signs for basilar artery thrombosis, a life-threatening disease. A 51-year-old woman complained of vertical diplopia for more than 20 h. A computed tomography of the brain was normal, but subsequently the patient developed additional symptoms including nausea, ventilation problems (dyspnoea) and somnolence. Neuro-ophthalmological evaluation revealed a skew deviation and a vertical nystagmus. Magnetic resonance imaging allowed the diagnosis of basilar artery occlusion. An emergency intervention with cerebral catheter angiography and local intra-arterial thrombolysis was performed. Total recanalization of the basilar artery was achieved resulting in a complete neurological recovery, including the skew deviation and nystagmus. This rare case of skew deviation associated with basilar artery occlusion was a diagnostic challenge and highlights adequate differential diagnosis. Skew deviation is an important clinical sign. In this patient it was the key to a correct diagnosis enabling an immediate and successful intervention.

[Diagnosis and therapy of basilar artery occlusion]

In view of the poor prognosis for untreated patients with basilar artery occlusion, rapid delivery of effective treatment has the highest priority. Early recanalization by intra-arterial thrombolysis can improve the outcome in some patients. Apart from this method, specialized centers are increasingly using mechanical devices and glycoprotein IIb/IIIa inhibitors to achieve recanalization. This review focuses on current developments in the diagnosis and treatment of acute basilar artery occlusion.