Basilar Stenosis Research Articles

Treatment and outcomes of acute intracranial vertebrobasilar artery occlusion: one institution's experience

The treatment of acute intracranial vertebrobasilar artery occlusion (VBO) has been described but often with poor results. The authors of this study set out to evaluate their institution's outcomes following multimodal treatment of VBO. They retrospectively reviewed their endovascular database for all patients treated for acute intracranial VBO between December 2004 and June 2010. Twenty-four patients were identified. Two patients were excluded from evaluation-one because of incomplete medical records and one because the etiology was basilar stenosis and not stroke. Occlusion location, hypercoagulable causes, time to endovascular treatment, time to revascularization, comorbidities, devices used, procedural anticoagulation, and outcomes were analyzed. Among the 22 eligible study patients, the mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15.3. The mean time from presentation to initiation of the endovascular procedure was 4.77 hours. The mean time for recanalization from the start of angiography was 1.63 hours. In 16 patients (73%), revascularization was successful (Thrombolysis in Myocardial Infarction [TIMI] score of 2 or 3). Thirteen (59%) of the 22 patients were discharged to home or a rehabilitation facility. One patient was transferred to a chronic care facility. The overall survival rate was 64%. The average NIHSS score for the 14 surviving patients at discharge was 3.9. At the follow-up (average 14.5 months, range 1-58 months), 10 patients (71%) had achieved good outcomes (modified Rankin Scale [mRS] score ≤ 2) and 4 (29%) had poor outcomes (mRS Score 3-6). Published case series have historically shown poor outcomes and high mortality rates in association with the treatment of acute VBO, prompting surgeons to be less aggressive in the treatment of this disease than they might be otherwise. Data in this series show that the revascularization of posterior circulation occlusions is feasible and that good outcomes and lower mortality rates with newer endovascular technologies are possible, and thus more prompt and aggressive treatment of this disease may be warranted.

De novo basilar artery aneurysm formation after placement of a Wingspan stent

Report the de novo formation of an aneurysm after wingspan placement and describe the treatment modality. We report a patient with symptomatic basilar stenosis who underwent placement of a wingspan stent. On 9-month follow-up, the patient was found to have a new 5-mm aneurysm adjacent to the proximal tines of the stent. The patient subsequently underwent placement of an enterprise stent and coils for aneurysm occlusion. We reviewed the literature and discussed possible etiologies for the development of this unique de novo aneurysm.

Endovascular Treatment of Symptomatic Radiation-Induced Basilar Artery Stenosis 25 Years after Medulloblastoma

Intracranial stenosis as late sequela after cerebral radiation therapy for medulloblastoma is an exceptionally rare finding. We report for the first time a case of 31-year-old patient with a history of medulloblastoma 25 years ago and now presenting with radiation-induced high-grade basilar stenosis and recurrent ischemic symptoms despite best medical therapy. The stenosis was treated successfully with angioplasty followed by stenting using a self-expandable microstent. Additionally, MRI revealed multiple cavernomas, illustrating that radiation-induced microbleeds may occur.

Treatment of atherosclerotic intracranial arterial stenosis.

David Pelz MD L. Nelson Hopkins MD Elad Levy MD Section Editors: Atherosclerotic stenosis of the major intracranial arteries (intracranial internal carotid artery, middle cerebral artery, vertebral artery, basilar artery) is probably the most common cause of stroke worldwide.1 Intracranial atherosclerosis causes 30% to 50% of strokes in Asia2 and 8% to 10% of strokes in North America.3 This review focuses on the medical and endovascular treatment of atherosclerotic intracranial arterial stenosis. Initially, a retrospective study suggested that warfarin was superior to aspirin for stroke prevention in patients with symptomatic intracranial arterial stenosis.4 This retrospective data combined with a proposed pathophysiological rationale for anticoagulation5 made warfarin a common treatment choice for symptomatic intracranial stenosis.6 However, the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial showed that aspirin was safer and as effective as warfarin for stroke prevention in patients with symptomatic intracranial stenosis. WASID was stopped early after a mean follow-up of 1.8 years because of higher rates of death and major hemorrhage in the warfarin arm. The primary end point of ischemic stroke, brain hemorrhage or vascular death, occurred in 22.1% of patients assigned aspirin and 21.8% of those in the warfarin group.7 The rates of myocardial infarction or sudden death were also higher in the warfarin arm. Certain high-risk subgroups of patients with intracranial stenosis were previously thought to benefit from anticoagulation, such as those with severe stenosis,4 vertebrobasilar disease,4 and those who have failed antithrombotic therapy.8 In WASID, however, patients with severe stenosis9 or those previously on antithrombotic therapy9,10 did not benefit from warfarin. Patients with basilar artery stenosis in WASID did appear to have a lower rate of the primary end point on warfarin, but there was no difference in the rate of stroke in the …

Infarctus cérébral, infection VIH et syphilis méningovasculaire : étude de trois cas

Introduction Various clinical manifestations can occur in syphilis, especially meningovascular syphilis. We report three cases of ischemic stroke related to meningovascular syphilis and HIV infection. Case reports Three men, aged 30, 31 and 41, presented typical neurologic deficit leading to the diagnosis of ischemic stroke. Radiographic investigations showed internal carotid thrombosis in two patients, and a basilar stenosis in the third. CSF analysis and blood samples revealed meningovascular syphilis associated with HIV infection. The other explorations were normal. Conclusion Due to the reemergence of syphilis, search for Treponema pallidum infection should be systematic in young stroke victims.

Retrograde angioplasty for basilar artery stenosis: bypassing bilateral vertebral artery occlusions

Basilar artery angioplasty with or without stenting is an emerging and promising treatment for vertebrobasilar insufficiency that is refractory to medical therapy. The usual approach is via a transfemoral route, with access directly through the vertebral artery (VA). An approach from the anterior circulation via the posterior communicating artery has been reported for optimal stent positioning and deployment across basilar apex aneurysms. No similar technique has been reported for treatment of midbasilar stenosis. The authors report a case of severe symptomatic basilar stenosis in which both VAs were occluded. The only option was to perform retrograde basilar angioplasty via the posterior communicating artery. This useful technique should be part of the armamentarium for the percutaneous treatment of symptomatic vertebrobasilar insufficiency for the occasional patient in whom occlusion or tortuosity precludes direct access to the VA.

Incidence and prognosis of >=50% symptomatic vertebral or basilar artery stenosis: prospective population-based study

The higher risk of early recurrent stroke after posterior circulation transient ischaemic attack or minor stroke versus after carotid territory events could be due to a greater prevalence of large artery stenosis, but there have been few imaging studies, and the prognostic significance of such stenoses is uncertain. Reliable data are necessary to determine the feasibility of trials of angioplasty and stenting and to inform imaging strategies. In the first-ever population-based study, we determined the prevalence of > or = 50% apparently symptomatic vertebral and basilar stenosis using contrast-enhanced MRA in consecutive patients, irrespective of age, presenting with posterior circulation transient ischaemic attack or minor ischaemic stroke in the Oxford Vascular Study and related this to the 90-day risk of recurrent transient ischaemic attack and stroke. For comparison, we also determined the prevalence of > or = 50% apparently symptomatic carotid stenosis on ultrasound imaging in consecutive patients with carotid territory events. Of 538 consecutive patients, 141/151 (93%) had posterior circulation events and had vertebral and basilar imaging, of whom 37 (26.2%) had > or = 50% vertebral and basilar stenosis, compared with 41 (11.5%) patients with > or = 50% ipsilateral carotid stenosis in 357/387 (92%) patients with carotid events who had carotid imaging (OR = 2.74; 95% CI = 1.67-4.51; P = 0.002). Presence of > or = 50% vertebral and basilar stenosis was unrelated to age, sex or vascular risk factors and, in contrast to > or = 50% carotid stenosis was not associated with evidence of coronary/peripheral atherosclerosis. In patients with posterior circulation events, > or = 50% vertebral and basilar stenosis was associated multiple transient ischaemic attacks at presentation (22% versus 3%; OR = 9.29; 95% CI = 2.31-37.27; P < 0.001) and with a significantly higher 90-day risk of recurrent events (OR = 3.2; 95% CI = 1.4-7.0; P = 0.006), reaching 22% for stroke and 46% for transient ischaemic attack and stroke. The prevalence of > or = 50% vertebral and basilar stenosis in posterior circulation transient ischaemic attack or minor stroke is greater than the prevalence of > or = 50% carotid stenosis in carotid territory events, and is associated with multiple transient ischaemic attacks at presentation and a high early risk of recurrent stroke. Trials of interventional treatment are therefore likely to be feasible, but more data are required on the long-term risk of stroke on best medical treatment.

The 59th Annual Meeting of the American Academy of Neurology, Boston, Massachusetts April 28-May 5, 2007

The 59th Annual Meeting of the American Academy of Neurology, Boston, Massachusetts April 28-May 5, 2007

Meningovascular syphilis as a cause of basilar artery stenosis

Syphilis is a rare but treatable cause of stroke in certain patients. We present a case of basilar stenosis and pontine stroke from meningovascular syphilis with clinical and radiographic improvement following treatment. A 40-year-old right-handed man presented with left-sided weakness and a soft voice. The patient’s symptoms started with lightheadedness and nausea, and progressed over hours to left-sided weakness involving the face, arm, and leg. He was brought to his local emergency department, where he had a normal general examination and dense left hemiparesis. MRI showed an infarct in the medial aspect of the right pons and suggested decreased flow in the basilar artery. The patient was transferred to the Neurologic Intensive Care Unit at our hospital. The review of systems was notable for lightheadedness on standing during the past month and a transient rash over the forearms 8 years prior. There was no known history of sexually transmitted disease. The mental status was normal except for a pseudobulbar affect; it was unclear how long this symptom had been …

Urgent endovascular revascularization for symptomatic intracranial atherosclerotic stenosis

Endovascular revascularization for intracranial atherosclerotic stenoses is being increasingly performed at major medical centers and has been reported to be technically feasible and safe. The authors report their experience with patients who underwent such a procedure for impending stroke and neurologic instability. All 18 patients (21 intracranial lesions) treated between 1997 and 2002 at the authors' institution with endovascular revascularization were retrospectively reviewed. Each patient had failed maximal medical therapy and was thought to be at high risk for an imminent stroke. Endovascular revascularization was performed on eight distal internal carotid artery lesions, six middle cerebral artery lesions, four intracranial vertebral artery lesions, and three basilar artery lesions. Recanalization was complete in 5 arteries (Thrombolysis in Myocardial Infarction [TIMI] Grade III), partial in 14 arteries (TIMI Grade II), and complete occlusion (TIMI 0) developed in 1 artery. In a patient with a tight basilar stenosis, no angioplasty could be performed because of the inability to cross the stenosis with the guidewire. Major periprocedural complications occurred in 9 (50%) patients: intracranial hemorrhage in 3 (17%), disabling ischemic stroke in 2 (11%), and major extracranial hemorrhage in 4 (22%). Three patients died: one from intracerebral hemorrhage and two from cardiorespiratory failure. Endovascular revascularization of intracranial vessels is technically feasible and may be performed successfully. However, periprocedural complication and fatality rates in neurologically unstable patients are high. The results suggest that patient selection, procedure timing, and periprocedural medical management are critical factors to reduce periprocedural morbidity and mortality.

Echo-Enhanced Transcranial Color Coded Duplexsonography versus Digital Subtraction Angiography for Diagnosis of Intracranial Vascular Diseases

P7 Objective: To assess the diagnostic efficacy of echo-enhanced transcranial color coded duplexsonography (eTCCD) for noninvasive evaluation of the intracranial vasculature in patients with cerebrovascular symptoms. MATERIAL AND METHODS: We prospectively evaluated 35 consecutive patients (10 women, 25 men, mean age 58,8 ± 9,7) with eTCCD (galactose palmitic acid based echo-enhancing agent) and digital subtraction angiography (DSA). All patients were admitted to our neurology department for acute onset of cerebrovascular symptoms. RESULTS: In 34/35 patients eTCCD visualized the circle of Willis. In 15/17 patients with critical symptomatic internal carotid artery obstruction (lumen diameter reduction of &gt;85% or occlusion) eTCCD correctly identified collateral flow patterns through the circle of Willis. DSA and eTCCD showed MCA-occlusion in 4 patients. In one of these patients eTCCD correctly identified a contralateral severe MCA-stenosis, which was first missed by DSA but confirmed by angiographic reevaluation. In 1 patient eTCCD missed occlusion of a M3-segment. In 2/3 patients eTCCD showed intracranial ICA-stenosis. In 3 patients with symptoms suggestive for basilar artery thrombosis DSA and eTCCD showed severe basilar stenosis in 1 patient and intracranial vertebral artery occlusion in 2 patients. DSA and eTCCD were normal in 3 patients with atypical intracranial hemorrhages and in 1 patient with subarachnoid hemorrhage. In another patient eTCCD correctly suggested a left parietooccipital AVM. DSA and eTCCD were normal in 4 other patients. CONCLUSION: eTCCD reliably detects occlusion, stenosis and collateral flow patterns of the basal cerebral arteries in patients with cerebral ischemia. For patients with cerebral hemorrhage our data are limited.

Microsurgical reconstruction of the posterior circulation.

Thirty-four patients with vertebrobasilar Insufficiency (VBI) were evaluated between 1974 and 1982. Twenty-two presented with transient VBI and 12 with residual strokes. The frequency of preoperative symptoms varied from once or twice a month to multiple daily events. Four patients with high-grade vertebral stenosis were treated by local vertebral endarterectomy at the C1 level. Seven patients underwent an anastomosis of the occipital artery to the posterior inferior cerebellar artery for distal vertebral basilar junction stenosis or occlusion. Three patients underwent anastomosis of the occipital artery to the anterior inferior cerebellar artery for vertebral basilar junction occlusion. Twenty patients underwent anastomosis of the superficial temporal to the superior cerebellar artery for distal vertebrobasilar junction stenosis or occlusion or midbasilar occlusive lesions. In 26 of 27 patients (95%), the anastomoses were patent. Two patients died, one from congestive heart failure and one from a brain stem infarct. Immediate complications included meningitis, CSF leaks, temporal lobe swelling, and seizures. Although the early surgical morbidity is high, it is only transient. Twenty-six patients have had complete resolution of their symptoms, and three have minor residual dizziness. Long-term morbidity has been limited to a patient with residual Wallenberg's syndrome secondary to the surgical occlusion of the vertebral artery, a patient who remained in a locked-in syndrome as before surgery, and a patient who developed Brown-Séquard syndrome. No further VBI symptoms occurred in one patient who died 4 years after surgery of a myocardial infarction. We believe the surgical approach to the vertebrobasilar area is feasible and can lead to the ultimate recovery of most patients.