Cause Of Transient Ischemic Attacks Research Articles

Severe hypocalcemia as a cause of transient ischemic attack? A debatable case and evidence from literature.

Hypocalcemia and transient ischemic attack (TIA) are different medical disorders; however, limited evidence suggests a possible link between the two. The underlying pathomechanisms by which hypocalcemia may cause cerebrovascular damage are difficult to comprehend. The aim of the study was to present an individual experiencing TIA that possibly due to severe hypocalcemia that associated with hypoparathyroidism after total thyroidectomy; and to explore the available evidence of its cause-effect relationship through available literature. A 68-year-old man presented to Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with complaints of weakness, especially in the right limbs that had worsened in the last week. The patient experienced unconsciousness for an hour before the admission; disorientation and anterograde amnesia over the time of recovering of consciousness. Other complaints included frequent muscle cramps, numbness in both arms and legs, dizziness, swallowing difficulty, nausea, and vomiting. The patient had a history of total thyroidectomy for a large struma diffuse 18 years ago and was prescribed several medications. However, the patient was overwhelmed by forgetfulness which had become more frequent in recent months resulting in medication nonadherence. The vital sign was stable and Chovsteck's sign was positive. The Montreal Cognitive Assessment (MoCA) revealed impairment in the visuospatial/executive component and delayed memory. Laboratory tests revealed severe hypocalcemia, altered thyroid function, hypomagnesemia, elevated D-dimer and fibrinogen, and vitamin D deficiency. TIA and severe hypocalcemia were proposed as the diagnosis. Prompt initiation of appropriate treatment, including calcium supplementation, anticoagulation, and neuroprotective agents, led to significant clinical improvement. Evidence from available literature suggests that there is a possible link between severe hypocalcemia and TIA that occurred in this patient. However, more studies are warrant to establish this cause-effect relationship.

The genetic landscape and clinical implication of pediatric Moyamoya angiopathy in an international cohort

Pediatric Moyamoya Angiopathy (MMA) is a progressive intracranial occlusive arteriopathy that represents a leading cause of transient ischemic attacks and strokes in childhood. Despite this, up to now no large, exclusively pediatric MMA cohort has been subjected to systematic genetic investigation. In this study, we performed molecular karyotyping, exome sequencing and automated structural assessment of missense variants on a series of 88 pediatric MMA patients and correlated genetic, angiographic and clinical (stroke burden) findings. The two largest subgroups in our cohort consisted of RNF213 and neurofibromatosis type 1 (NF1) patients. While deleterious RNF213 variants were associated with a severe MMA clinical course with early symptom onset, frequent posterior cerebral artery involvement and higher stroke rates in multiple territories, NF1 patients had a similar infarct burden compared to non-NF1 individuals and were often diagnosed incidentally during routine MRIs. Additionally, we found that MMA-associated RNF213 variants have lower predicted functional impact compared to those associated with aortic disease. We also raise the question of MMA as a feature of recurrent as well as rare chromosomal imbalances and further support the possible association of MMA with STAT3 deficiency. In conclusion, we provide a comprehensive characterization at the genetic and clinical level of a large exclusively pediatric MMA population. Due to the clinical differences found across genetic subgroups, we propose genetic testing for risk stratification as part of the routine assessment of pediatric MMA patients.

LA strain helps identifying the cardioembolic etiology of transient ischemic attacks

Abstract Background Patients who have transient ischemic attacks (TIA) often suffer from asymptomatic and paroxysmal atrial fibrillation (AF). Due to the fact that AF is located in the atria, we sought to determine whether abnormalities in left atrial (LA) structure and function could help identify the cardioembolic cause of TIA in patients with sinus rhythm but with documented episodes of paroxysmal AF. Methods The research included 190 individuals with TIA and classified them into two groups based on the presence (group I) or absence (group II) of confirmed paroxysmal AF. The diagnosis of paroxysmal AF was established by an assessment of medical records. To prevent assessing atrial stunning, cardiac ultrasonography was conducted in sinus rhythm at least 14 days following the initiation the TIA. Results The results indicated that patients in group I were older, more often female, had a history of stroke or TIA, and had a higher CHA2DS2-VASc score. Additionally, they exhibited increased LA volumes, a decreased LA emptying fraction, and markedly altered LA deformation patterns. Three factors were found as being independently associated with paroxysmal AF using multivariate logistic regression: age, LA reservoir strain, and LA emptying fraction (P<0.0001). The variables had as cut-off values: age >55 years, LA reservoir strain<−17%, and LA emptying fraction <51%. Conclusion The current research establishes that LA strains are independently associated with paroxysmal AF in patients with TIA and may aid in determining the cardioembolic origin of these events. Our findings have considerable clinical implications because, until now, LA 2D-STE was not included in the usual evaluation of TIA patients, but it may be the ideal next step in this regard. Funding Acknowledgement Type of funding sources: None.

A rare cause of Transient ischemic attack in a young patient: left ventricular non-compaction with a voluminous thrombus

A rare cause of Transient ischemic attack in a young patient: left ventricular non-compaction with a voluminous thrombus

External Cardiac Loop Recorders: Functionalities, Diagnostic Efficacy, Challenges and Opportunities.

According to the World Health Organization's (WHO) report of 2016, cardiovascular diseases (CVDs) accounted for mortality of an estimated 17.9 million people globally. Of these deaths, 85% were due to myocardial infarction and stroke. Further, the pre-dominant atrial fibrillation (AF) arrhythmia has been the most suspected underlying cause of transient ischemic attack or stroke. Thus, the etiologies of early symptoms like syncope and palpitations in patients needs to be evaluated by employing proper diagnostic tests to make early treatment decisions. The most widely referred 24 to 48 hour Holter electrocardiographic (ECG) monitoring tests have not been proved to be much effective in recognizing infrequent intermittent arrhythmic episodes. These drawbacks have led to the development of long-term ambulatory ECG (AECG) monitoring devices. This review reports the state-of-the-art existing AECG monitoring devices and their role of long-term ECG recording in patients suspected with cardiac syncope and palpitations to understand the underlying arrhythmic cause, as well as in the diagnosis and management of AF. Primarily, the utility and diagnostic yield of external cardiac recorders or event loop recorders (ELRs) in capturing the symptom-rhythm correlation which constitutes a clinically useful recordings of heart's electrical activity during infrequent arrhythmic conditions was critically reviewed. Furthermore, a brief case study on challenges involved in clinical data acquisition at a cardiac care unit using ambulatory external monitoring device has been presented. Finally, improvements in design engineering and algorithmic developments to enhance the diagnostic yield and usability of ELRs in clinical settings have been proposed.

A Treatment Option for Symptomatic Chronic Complete Internal Carotid Artery Occlusion: Hybrid Surgery.

BackgroundInternal carotid artery occlusion (ICAO) is a relatively uncommon but important cause of transient ischemic attack and cerebral infarction. The majority of cases of symptomatic ICAO requires surgical treatment. In this study we performed an investigation of the efficacy and safety of hybrid surgery which is a surgical method for symptomatic chronic complete ICAO.MethodsFifty-five patients with symptomatic chronic ICAO treated by hybrid surgery from 2016 to 2019 were included. We recorded and analyzed the patients’ clinical characteristics, angiographic data, recanalization rate, complications, and outcomes. Catheter angiography or computed tomography angiography was used to assess the patency of the recanalized ICA during follow-up.ResultsThe total success rate of recanalization was 78.2% (43/55). The occlusions were significantly shorter in the success than failure group (5.40 ± 1.50 vs. 7.56 ± 0.99 cm, respectively; P < 0.001). The median duration of ICA occlusion was significantly shorter in the success than failure group (90 vs. 200 days, respectively). The success rates of distal ICA recanalization at the petrous segment or below, cavernous segment, and clinoid segment or above were 100, 33.3, and 14.3%, respectively (P < 0.001). Multivariate analysis showed that the level of distal ICA reconstitution was the only factor affecting the recanalization success rate. Periprocedural complications included hyperperfusion syndrome (n = 1) and laryngeal nerve injury (n = 1). ICA reocclusion occurred in one patient (2.3%). Significant postoperative improvement in symptoms was observed in the success group, with a median modified Rankin scale score of 0 at the 3-month follow-up compared with before recanalization (median, 1) (P<0.001).ConclusionHybrid surgery might be safe and effective for patients with symptomatic chronic complete ICAO. The level of distal ICA reconstitution is a predictor of successful recanalization in hybrid operations.

Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects.

Intracranial atherosclerotic stenosis (ICAS) is a common cause of transient ischemic attack (TIA) and ischemic stroke. Endovascular treatment, including balloon angioplasty alone, balloon-mounted stents, and self-expandable stent placement with or without prior angioplasty, is an alternative to medical treatment for the prevention of recurrent TIA or ischemic stroke in patients with ICAS. Although the SAMMPRIS and VISSIT trials supported medical management alone against endovascular treatments, both randomized controlled trials (RCT) were criticized due to flaws relating to patient-, intervention-, and operator-related factors. In this review, we discuss the current debate regarding these aspects and suggest approaches to solve current controversies in the future. In our opinion, endovascular treatment in carefully selected patients, individualized choice of endovascular treatment subtypes, and an experienced multidisciplinary team managing the patient in the pre-, peri- and post-procedural period have the potential to provide safe and efficious treatment of patients with symptomatic ICAS.

Spontaneous Carotid Artery Dissection Presenting with Headache

Introduction: Carotid artery dissection, an infrequent cause of transient ischemic attack and stroke among younger patients, is being increasingly diagnosed. Thromboembolic events occur following carotid artery dissection due to the narrowing of the lumen, which is a potentially life-threatening condition that can cause long-term neurological disabilities. We report a case with internal carotid artery dissection and emphasize the importance of differential diagnoses for headache and neck pain in the young and middle-aged population. Case Report: A 33-year-old female patient was admitted to the emergency department because of headache, neck pain, speech impairment, and weakness on her right side, which persisted for five hours. She had revealed signs of confusion for the last two hours. There was no history of trauma. We received the information from her husband. The neurological examination revealed a weakness on the right upper extremity and non-fluent aphasia. She had normal results from coagulation tests. Occlusion secondary to dissection with a cervical computed tomography angiography was indicated. Low molecular weight heparin and warfarin were administered. Conclusion: It should be kept in mind that carotid artery dissection can be asymptomatic until ischemic symptoms occur. Emergency physicians should consider carotid artery dissection in young patients who present with neck pain and headache

Patent foramen ovale and stroke in childhood: A systematic review of the literature.

Stroke in association with a patent foramen ovale (PFO) may be due to paradoxical embolization via a right to left intracardiac shunt but the exact contribution of PFO to stroke or stroke recurrence in childhood remains unclear. To review the relationship of a PFO with stroke, and evaluate associated co-morbidities. An electronic database literature search of Pubmed, Cochrane and EMBASE was performed from January 2000-December 2014. 149 articles were retrieved, with overlap for diagnosis, management, treatment and outcome. 65 reports were utilized for the comprehensive review. Majority of childhood arterial ischemic stroke and transient ischemic attacks are associated with prothrombotic disorders or arteriopathy. Transthoracic echocardiography with a Valsalva maneuver is highly sensitive as a screening tool but may be falsely positive. Transthoracic echocardiography with color Doppler and a concurrent bubble contrast study are excellent for visualizing the atrial septum and PFO and identifying a right to left shunt. Current literature does not support PFO closure for cryptogenic stroke in young adults without an associated risk of thromboembolism. High quality research in the pediatric population is lacking and most of the data is extrapolated from adults. Paradoxical embolism from a PFO as a cause of transient ischemic attack or stroke is a diagnosis of exclusion. PFO closure should be individualized based on significant shunting and risk factors such that maximum benefit is derived from the procedure. A young person with a PFO and stroke should be thoroughly investigated to rule out other etiologies.

One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke

BackgroundPrevious studies conducted between 1997 and 2003 estimated that the risk of stroke or an acute coronary syndrome was 12 to 20% during the first 3 months after a transient ischemic attack (TIA) or minor stroke. The TIAregistry.org project was designed to describe the contemporary profile, etiologic factors, and outcomes in patients with a TIA or minor ischemic stroke who receive care in health systems that now offer urgent evaluation by stroke specialists.MethodsWe recruited patients who had had a TIA or minor stroke within the previous 7 days. Sites were selected if they had systems dedicated to urgent evaluation of patients with TIA. We estimated the 1-year risk of stroke and of the composite outcome of stroke, an acute coronary syndrome, or death from cardiovascular causes. We also examined the association of the ABCD2 score for the risk of stroke (range, 0 [lowest risk] to 7 [highest risk]), findings on brain imaging, and cause of TIA or minor stroke with the risk of recurrent stroke over a period of 1 year.ResultsFrom 2009 through 2011, we enrolled 4789 patients at 61 sites in 21 countries. A total of 78.4% of the patients were evaluated by stroke specialists within 24 hours after symptom onset. A total of 33.4% of the patients had an acute brain infarction, 23.2% had at least one extracranial or intracranial stenosis of 50% or more, and 10.4% had atrial fibrillation. The Kaplan–Meier estimate of the 1-year event rate of the composite cardiovascular outcome was 6.2% (95% confidence interval, 5.5 to 7.0). Kaplan–Meier estimates of the stroke rate at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively. In multivariable analyses, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than a doubling of the risk of stroke.ConclusionsWe observed a lower risk of cardiovascular events after TIA than previously reported. The ABCD2 score, findings on brain imaging, and status with respect to large-artery atherosclerosis helped stratify the risk of recurrent stroke within 1 year after a TIA or minor stroke. (Funded by Sanofi and Bristol-Myers Squibb.)

Symptomatic carotid stenosis and stroke risk in patients with transient ischemic attack according to the tissue-based definition

Background and Purpose: Symptomatic carotid stenosis (sCS), a common cause of transient ischemic attack (TIA), is correlated with higher stroke risk. We investigated the frequency and associated factors of sCS in patients with TIA and the association between sCS and stroke risk following TIA. Methods: Over a three-year period (2011–2013), 861 consecutive patients with TIA, who were admitted to the Department of Neurology at the University of Lübeck, Germany, were included in a monocenter study and prospectively evaluated. Diagnosis of TIA was in accordance with the tissue-based definition (transient neurological symptoms without evidence of infarction by brain imaging). Results: Of 827 patients (mean age, 70 ± 13.2 years; 49.7% women), 64 patients (7.7%; 95% confidence interval [CI], 5.9%–9.7%) exhibited sCS and 3 patients (0.3%) showed an occlusion of the corresponding internal carotid artery. Logistic regression revealed that sCS was associated with male sex (odds ratio [OR], 2.7; 95% CI, 1.2–3.6; p = 0.012), amaurosis fugax (OR, 8.1; 95% CI, 3.4–19–4; p < 0.001), unilateral weakness (OR, 3.4; 95% CI, 1.9–6.1; p < 0.001), symptom duration less than 1 h (OR, 2.0; 95% CI, 1.1–3.4; p = 0.019) and previous stroke (OR, 2.7; 95% CI, 1.5–4.7; p = 0.001). During hospitalization (mean, 6.6 days), five patients (0.6%; 95% CI, 0.1%–1.2%) suffered from stroke. The stroke risk was higher in patients with sCS than in those without sCS (6.3% vs. 0.1%; p < 0.001), whereas the recurrent TIA risk (2.6%) did not differ between the groups (4.7% vs. 2.5%; p = 0.29). Conclusion: SCS appears to be associated with a higher risk of stroke in patients with TIA defined according to the tissue-based definition.

Factors associated with early recurrence at the first evaluation of patients with transient ischemic attack

We aimed to identify factors easily collected at admission in patients with transient ischemic attack (TIA) that were associated with early recurrence, so as to guide clinicians’ decision-making about hospitalization in routine practice. From September 2011 to January 2013, all TIA patients who were referred to the University Hospital of Dijon, France, were identified. Vascular risk factors and clinical information were collected. The etiology of the TIA was defined according to the results of complementary examinations performed at admission as follows: large artery atherosclerosis (LAA-TIA) TIA, TIA due to atrial fibrillation (AF-TIA), other causes, and undetermined TIA. Logistic regression analyses were performed to identify factors associated with any recurrence at 48hours (stroke or TIA). Among the 312 TIA patients, the etiology was LAA-TIA in 33 patients (10.6%), AF-TIA in 57 (18.3%), other causes in 23 (7.3%), and undetermined in 199 (63.8%). Early recurrence rates were 12.1% in patients with LAA-TIA, 5.3% in patients with AF-TIA, 4.3% in patients with another cause of TIA, and 1.0% in patients with undetermined TIA. In multivariable analysis, the LAA etiology was independently associated with early recurrence (odds ratio [OR]: 12.03; 95% confidence interval [CI]: 1.84–78.48, p=0.009). A non-significant trend was also observed for AF-TIA (OR: 3.82; 95% CI: 0.40–36.62, p=0.25) and other causes (OR: 3.73; 95% CI: 0.30–46.26, p=0.31). A simple initial assessment of TIA patients in the emergency room would be helpful in targeting those with a high risk of early recurrence and who therefore need to be hospitalized.

Aortic arch atheroma in transient ischemic attack patients

ObjectiveAortic arch atheroma (AAA) is associated with vascular risk factors and with stroke risk. Its prevalence and prognosis remain to be defined in patients with transient ischemic attack (TIA). MethodsUsing data from the SOS-TIA registry, we assessed the prevalence of AAA detected by transesophageal echocardiography (TEE). AAA was graded as moderate (<4 mm) or severe (≥4 mm). All patients had a standardized work-up investigation and were followed for 1 year. ResultsBetween January 2003 and December 2008, 1850 patients with definite/possible TIA or minor stroke were enrolled and 1231 (67%) underwent TEE. Moderate AAA was found in 26% of patients (n = 324) and severe AAA in 14% (n = 171), giving an overall AAA prevalence of 40%. Among the 873 patients without identified cause of TIA, the prevalence of moderate and severe AAA were 24% and 12% respectively. Intracranial or extracranial stenosis ≥50% were detected in 21% of patients and were independently associated with AAA (adjusted odds ratio, 1.65, 95% confidence interval (CI), 1.23–2.22). At one-year, incidence of recurrent vascular events was 2.2% in patients without AAA, 4.1% in moderate AAA and 6.6% in severe AAA (log-rank, p for trend = 0.003). Using patients without AAA as reference, and after adjustment on vascular risk factors, the hazard ratio (95% CI) for moderate was 1.36 (0.62–2.99) and 2.08 (0.89–4.86) for severe (p for trend = 0.095). ConclusionsThese findings support a systematic identification of AAA in TIA patients to optimize risk stratification in this specific population.

Elongated Styloid Process as a Cause of Transient Ischemic Attacks

A 49-year-old man had been experiencing transient right-sided weakness during neck rotation and flexion to the left for 1 year. On hospital admission, a neurological examination revealed no deficits. Initialmagnetic resonance imaging of the brainwas unremarkable. The first computed tomographic (CT) angiographyof thebrain and neck revealed no abnormal findings. Catheter cerebral angiography,performedwiththepatient’sheadturnedtothe left (Figure1), demonstrated a filling defect fromwhat appears to be an extrinsic compression.ThesecondCTangiographyof thebrainandneckperformed with the patient’s head turned to the left (Figure 2 and Figure 3) revealed a left cervical internal carotid artery (ICA) compression due to an elongated styloid process. The elongated styloidprocesswasremovedduringsurgery,afterwhichthepatienthad a satisfactory recovery. Postoperative CT angiography of the brain and neck (Figure 4) revealed that the left cervical ICA was free of compression. This case suggests the usefulness of dynamic catheter and CT angiography for the diagnosis of an elongated styloid process as a cause of transient ischemic attack.

Angina Pectoris or Myocardial Infarctions, Pulmonary Arteriovenous Malformations, Hereditary Hemorrhagic Telangiectasia, and Paradoxical Emboli

Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder characterized by vascular malformations, and many clinical complications are related to pulmonary arteriovenous malformations (PAVMs) because they provide direct right-to-left shunts. Paradoxical emboli through these shunts are a well-recognized cause of transient ischemic attack, stroke, and cerebral abscess. The aim of this study was to determine whether paradoxical emboli through PAVMs could manifest as cardiac ischemic events. The study included a single-center population of 98 patients with PAVMs. Eighty-four had undergone PAVM embolotherapy, and the remaining 14 patients had PAVMs too small to require embolization. Patients were interviewed by telephone and surveyed regarding their cardiopulmonary symptoms and histories of cardiac diagnoses. We found that 6 patients (which is 18% of patients with symptomatic PAVMs, n = 33, and 6% of the total cohort, n = 98) reported that they had experienced typical angina pectoris-like chest pain or had a myocardial infarction before PAVM embolotherapy. Five patients had had a cardiac catheterization, 4 had normal coronary arteries, and 1 had a single artery occlusion. In conclusion, we suggest that in patients with untreated PAVMs, cardiac ischemia can occur because of a paradoxical embolus through PAVMs to a coronary artery.

Transcatheter Treatment of Patent Foramen Ovale Combined with Abnormal Drainage of Left Superior Vena Cava to Left Upper Pulmonary Vein

Patent foramen ovale (PFO) has been known to be the cause of transient ischemic attacks or stroke, and transcatheter device closure has been the treatment of choice for these defects. Combined defect of abnormal drainage of left superior vena cava (LSVC) to left superior pulmonary vein (LSPV) in PFO patients is an uncommon combination, and both can act as a pathway for paradoxical embolism. We report a successful closure of PFO, using Amplatzer® PFO occluder (St. Jude Medical, St. Paul, MN, USA) and persistent LSVC connected to LSPV using an Amplatzer® Vascular Plug II (St. Jude Medical, St. Paul, MN, USA). Because this combined anomaly of PFO and persistent LSVC can be treated by a single transcatheter intervention, if clinically suspected, a complete evaluation for this anomaly should be considered.

The Evolution and Role of Endovascular Therapy for the Treatment of Intracranial Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is being seen as an increasingly important cause of transient ischemic attack and stroke. Attention on this disease entity has been focused as a result of two recent events: the publication of the WASID trial and the recent Food and Drug Administration approval of the Wingspan-Gateway stent system. This manuscript will review the evolution of the role of endovascular therapy in the management of ICAD. In addition, the available devices currently available for endovascular therapy will be reviewed with an eye toward peri-procedural and follow-up complication rates.

D-dimer, Magnetic Resonance Imaging Diffusion-weighted Imaging, and ABCD 2 Score for Transient Ischemic Attack Risk Stratification

We sought to determine whether measurement of D-dimer (DD) would improve risk stratification after transient ischemic attack (TIA). We enrolled 167 patients with acute TIA in a prospective observational study. DD was measured using rapid enzyme-linked immunosorbent assay. The primary outcome measure was a composite end point consisting of stroke or death within 90 days or the identification of a high-risk stroke mechanism requiring specific early intervention (defined as > or =50% stenosis in a vessel referable to symptoms or a cardioembolic source warranting anticoagulation). The composite end point occurred in 41 patients (25%). A 50% or greater stenosis was found in 25 patients (15%), a cardioembolic source in 14 (8%), and clinical events in 8 (5 strokes, 3 deaths), 6 of whom also had a high-risk cause of TIA. ABCD(2) score was associated with outcome (P for trend = .017, c-statistic 0.63). DD levels did not differ based on outcome status (geometric mean 0.75 v 0.82 microg fibrinogen equivalent unit/mL, P = .56), and DD had little use for predicting outcome (c-statistic 0.57), even when combined with ABCD(2) score. Of 96 patients with early magnetic resonance imaging (MRI), 23% had diffusion-weighted imaging (DWI) abnormalities, and MRI DWI was predictive of outcome (c-statistic 0.76). The addition of MRI DWI to ABCD(2) improved predictive accuracy (c-statistic 0.83) compared with either alone. Many patients with TIA have a high-risk mechanism (large vessel stenosis or cardioembolism) or will experience stroke/death within 90 days. Increasing ABCD(2) scores were associated with this composite end point. Measurement of DD did not provide additional prognostic information.

Rotational vertebrobasilar ischemia due to vertebral artery dynamic stenoses complicated by an ostial atherosclerotic stenosis

We describe a patient with rotational vertebrobasilar ischemia (RVBI) due to vertebral artery (VA) compressive stenoses during neck rotation, complicated by an ostial atherosclerotic stenosis (OAS). Referred for 'near-syncopal spells', inquiry revealed a symptom-complex consistent with vertebrobasilar transient ischemic attacks (TIAs) provoked by head rotation. VA dynamic angiography with imaging via prevertebral subclavian injections in neck-rotated positions while reproducing symptoms, demonstrated two compressive stenoses not present in the neck-neutral position, establishing the diagnosis of RVBI due to CT-demonstrated cervical spondylosis. There was an occluded contralateral VA, isolated posterior circulation, and absent vertebral collateral flow. Disabling symptoms persisted despite using a cervical collar. Surgical decompression of the dynamic stenoses would not address the OAS, was considered high risk, and absence of a suitable donor artery precluded distal VA reconstruction. RVBI resolved with ostial stent placement by improving perfusion pressure across the compressive stenoses. To our knowledge, this is the first report of RVBI in which the affected VA had an obstructive atherosclerotic stenosis in addition to the characteristic rotation-induced dynamic stenoses, and the first report of stent placement in the culprit artery to treat this disorder. Diagnosis depends on recognizing the association of symptoms with positional neck changes and VA dynamic angiography demonstrating the compressive stenosis while reproducing symptoms. This case illustrates the management complexities when there are coexisting abnormalities, emphasizing the need to individualize treatment. RVBI is a potentially correctable cause of TIAs and particularly relevant due to the aging population which has a significant incidence of both degenerative cervical and atherosclerotic cerebrovascular disease.

21 Unusual neck artery branching as a cause of transient ischemic attacks

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.