Intracranial Vertebral Artery Research Articles

Flow-Diverting Devices in the Treatment of Vertebral Artery Aneurysms: Insights into Efficacy and Safety from a Systematic Review and Meta-analysis.

The objective of this study is to conduct a systematic review and meta-analysis aimed at evaluating the efficacy and safety of flow-diverting devices (FDs) treatment for intracranial vertebral artery (VA) aneurysms. We searched PubMed, Web of Science, OVID, and Embase for English-language studies up to February 2024 and included clinical studies on FD treatment of intracranial VA aneurysms. Sensitivity analysis evaluated outcome stability. Of 2273 articles, 29 studies involving 541 aneurysms treated with FDs were included. Based on the Methodological Index for Non-Randomized Studies (MINORS), six were high-quality and 23 moderate quality. FD treatment showed a 95% rate of favorable clinical outcomes (95% CI, 89-99%), 81% (95% CI, 74-88%) complete aneurysmal occlusion, 4% (95% CI, 2-7%) ischemic complication incidence, 1% (95% CI, 0-3%) hemorrhagic complication incidence, 95% (95% CI, 87-100%) posterior inferior cerebellar artery (PICA) preservation, and 6% (95% CI, 3-10%) in-stent stenosis or occlusion across clinical and angiographic follow-up periods of 13.62months (95% CI, 10.72-16.52) and 11.85months (95% CI, 9.36-14.33), respectively. Subgroup analyses, based on a 12-month angiographic follow-up threshold, indicated no statistically significant differences in rates of complete aneurysm occlusion, PICA preservation, or in-stent stenosis or occlusion incidence (p > 0.05) between subgroups. Moreover, significant differences were observed in clinical and angiographic outcomes between ruptured and unruptured aneurysms, particularly in hemorrhagic complications (p < 0.05), without significant disparity in ischemic complications (p > 0.05). The results' stability was confirmed via sensitivity analysis. FDs treatment for VA aneurysms is efficacious and safe, offering high rates of positive clinical and angiographic outcomes with minimal complications, underscoring FDs' viability as a treatment option for VA aneurysms. The study was registered with PROSPERO (registration number: CRD42024499894).

Flow diverters versus stent-assisted coiling in unruptured intracranial vertebral artery dissecting aneurysms.

Flow diverters (FDs) have been used in unruptured intracranial vertebral artery dissecting aneurysms (IVADAs) with seemingly more favorable outcomes compared with stent-assisted coiling (SAC). However, the benefits of FDs over SAC in unruptured IVADAs need further evaluation. This was a propensity score-matched, retrospective cohort study. Consecutive patients with unruptured IVADAs treated with FDs or SAC at the authors' hospital between January 2016 and December 2020 were reviewed. Propensity score matching at 1:1 was based on age, significant stenosis adjacent to aneurysmal dilatation, maximum diameter, and posterior inferior cerebellar artery involvement. Periprocedural cerebrovascular complications and angiographic and clinical outcomes were compared between the two matched groups. A total of 124 unruptured IVADAs in 123 patients (median age 53 [interquartile range 47-59] years; 101 men) were included. The FD and SAC groups included 65 and 59 IVADAs, respectively. Propensity score matching resulted in 47 matched pairs. The rates of immediate complete occlusion were significantly lower in the matched FD group than in the matched SAC group (6.4% vs 68.1%, p < 0.001). The rates of periprocedural cerebrovascular complications were comparable between the two matched groups (6.4% vs 6.4%, p > 0.99). At last follow-up, the rates of complete occlusion (89.4% vs 80.9%, p = 0.39) and favorable clinical outcomes (100.0% vs 97.9%, p > 0.99) were comparable, whereas the rate of recanalization was significantly lower in the matched FD group than in the matched SAC group (0.0% vs 12.8%, p = 0.03). Although the difference between the rates of in-stent stenosis was not statistically significant (17.0% vs 6.4%, p = 0.18), the difference in the effect measures was considerable. In unruptured IVADAs and compared with SAC, FDs provide comparable rates of periprocedural cerebrovascular complications, favorable clinical outcomes, and follow-up complete occlusion, lower rates of immediate complete occlusion and follow-up recanalization, and likely higher rates of in-stent stenosis.

Endovascular treatment of symptomatic severe intracranial atherosclerotic stenosis with a novel intracranial dedicated drug-eluting stent: a more effective treatment approach.

Endovascular treatment of severe intracranial atherosclerotic stenosis (ICAS) using coronary drug-eluting stents (DESs) significantly reduces the risk of in-stent restenosis (ISR) and stroke recurrence. However, there are few reports regarding the treatment of ICAS with intracranial dedicated DES. Herein, we present our experience with the feasibility, safety, and medium-term follow-up outcomes of a novel intracranial DES, named NOVA stent, in patients with symptomatic severe ICAS (≥70%). From December 2021 to May 2022, patients with symptomatic severe ICAS who underwent implantation of the NOVA stent in our institution were retrospectively analyzed for procedural results, perioperative complications, imaging and clinical follow-up outcomes. Twenty-four patients, 16 (66.7%) with anterior circulation lesions and 8 (33.3%) with posterior circulation lesions, were enrolled. All patients with intracranial ICA (n = 6), middle cerebral artery (n = 10), basilar artery (n = 3), intracranial vertebral artery (n = 3), and the vertebrobasilar junction (n = 2) stenosis were treated successfully using NOVA stents. The severity of stenosis ranged from 75 to 96% (mean 85.9%) before treatment and this was reduced to 0 to 20% (mean 8.6%) immediately after stent placement. Symptomatic distal embolism occurred in one case; however, there were no other perioperative complications. The mean follow-up duration was 12.2 ± 1.06 months. No symptomatic ischemic events occurred during follow-up. Follow-up cerebral angiography was performed in 22 of 24 patients (91.7%), and significant ISR occurred in one patient (4.2%). Our results demonstrate that implantation of the novel intracranial DES NOVA in severe ICAS is feasible, safe, and effective in selected cases, reducing the incidence of ISR, and showing excellent midterm clinical outcomes, providing a promising option for ICAS treatment.

Effects and safety of endovascular recanalization for non-acute symptomatic intracranial vertebral artery occlusion with different risks.

There is no consensus on the optimal treatment for non-acute symptomatic intracranial vertebral artery occlusion, and endovascular recanalization is a challenging procedure. We report our clinical experience of endovascular recanalization in patients with non-acute symptomatic intracranial vertebral artery occlusion to assess the feasibility and safety of endovascular recanalization and determine the candidate patients for this procedure. Ninety-two patients with non-acute symptomatic intracranial vertebral artery occlusion who underwent endovascular recanalization from January 2019 to December 2021 were retrospectively analyzed. we grouped all patients according to imaging examination findings, occlusion length, duration, nature, calcification, and angulation to evaluate the risk of endovascular recanalization. The overall success rate of endovascular recanalization was 83.7% (77/92), and the perioperative complication rate was 10.9% (10/92). Among the 3 classification groups, the recanalization success rate gradually decreased from the low-risk group to the high-risk group (low-risk: 100%, medium-risk: 93.3%, high-risk group: 27.8%, P = .047), while the overall perioperative complication rate showed the opposite trend (0%, 10.0%, 38.9%, respectively, P = .001); the proportion of patients with 90-day modified Rankin Scale scores of 0-2 decreased successively (100%, 83.3%, and 22.2%, respectively, P < .026); 77 patients with successful recanalization were followed; the rate of restenosis/reocclusion increased sequentially (0%, 17.9%, and 80%, respectively, P = .000). Patients in the low- and medium-risk groups showed a good clinical course after endovascular recanalization. Among 88 patients (four patients lost to follow-up), with a median clinical follow-up of 13 months (interquartile range ¼, 7-16), the rate of stroke or death after 30 days was 17.4% (16/92). Endovascular recanalization is safe and feasible for low- and medium-risk patients with non-acute symptomatic intracranial vertebral artery occlusion; it is also an alternative to conservative therapy for the patients.

Embolization of an Intracranial Vertebral Artery Aneurysm via the Deep Cervical Artery.

Treatment of vertebral artery aneurysms can be challenging due to the unusual vascular anatomy or unfeasibility of traditional endovascular techniques. We describe a novel approach for endovascular treatment of a ruptured intracranial vertebral artery aneurysm with bilateral vertebral artery occlusions and hypoplasia of the posterior communicating arteries. Successful coil embolization was performed using a collateral pathway for microcatheterization via anastomosis between the deep cervical artery and the vertebral artery. This case report highlights a novel alternative endovascular treatment approach for vertebrobasilar aneurysms in case of a poor vascular status with occlusion or lack of traditional endovascular access routes.

Abstract TMP72: Impaired Perfusion Predicts Early Recurrence in Symptomatic Intracranial Atherosclerosis

Background: Intracranial Atherosclerosis (ICAS) leads to stroke by perforator disease, artery to artery embolism, and impaired distal flow/perfusion. While medical treatment is likely to stabilize atherosclerotic plaques, it is unlikely to improve distal perfusion in the acute setting. We hypothesize that medically treated patients with symptomatic ICAS with impaired perfusion have a high risk of recurrence. Methods: We included hospitalized patients with acute ischemic stroke due to ICAS involving the intracranial ICA, proximal MCA, intracranial vertebral artery, or basilar artery over a 3 year period. Patients were treated with medical treatment and followed for 30-days post stroke. Patients generally underwent perfusion imaging with MRI. The study outcome is recurrent ischemic stroke. We used univariate and multivariable Cox regression analyses to determine the association between risk factors, treatment strategies, perfusion delay at T max 4 sec and 6 sec thresholds. To account for multiple admissions per patient, we used robust variance estimator clustering on individual patients. Results: Over the study period, we identified 96 hospitalizations for symptomatic ICAD over 3 years. The recurrence risk within 30 days was 17.7% (17/96). In univariate analysis, factors associated with recurrent risk at 30 days were lack of dual antiplatelet therapy (47.1% versus 22.8%, P=0.068), increased Tmax perfusion mismatch volume as 6 sec (10[0-51] versus 0[0-0], P=0.008) and at 4 sec (60[37-170] versus 13.5[0-91], P=0.050). Using Youden’s index, we identified cutoffs of 6.5 ml and 35.5 ml for Tmax 6 sec mismatch and Tmax 4 sec mismatch respectively. In Cox regression analyses, only predictors of recurrence were T max 6 sec perfusion mismatch &gt; 6.5 ml (aHR 6.72 95% CI 2.01-22.45 p=0.002) and T max 4 sec perfusion mismatch &gt; 35.5 ml (aHR 5.78 95% CI 1.53-21.81 p=0.010). Dual antiplatelet therapy was not associated with reduced recurrence risk (p&gt;0.05) in all models. Conclusions: Patient with symptomatic ICAS and impaired distal perfusion are at high risk of early recurrence. Studies testing reperfusion should focus on this subgroup and enroll patients early, when the risk of recurrence in medically treated patients is highest and likely driven by reperfusion.

Abstract 85: One-year Outcomes After Endovascular Treatment for Posterior Circulation Tandem Occlusions: A Multicenter Experience of 249 Patients

Introduction: Endovascular thrombectomy (EVT) in posterior circulation tandem occlusions can be challenging and the current evidence is limited to retrospective case series with small sample sizes. Method: Consecutive patients from both PRESIST (ChiCTR2000033211) and BASILAR (ChiCTR1800014759) prospective registries between 2014 and 2022 were included with a total of 53 centers. Posterior circulation tandem occlusion was defined as stroke due to intracranial vertebral (V4), basilar, or posterior cerebral artery (PCA) occlusions, with tandem steno-occlusive lesion &gt;70% of the extracranial vertebral artery and impaired distal flow or partial filling of the VA from collaterals. Outcomes included successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) of 2b-3, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-3, and mortality, at 90 day and 1-year. Results: After excluding 14 cases with failed access/penetration, a total of 249 patients (mean age of 63.9 years [SD 11.7], 208 [83.5%] male) were included. Basilar artery occlusions were recorded in 179 patients (71.9%) followed by V4 occlusions in 64 patients (25.7%) and PCA occlusions in 6 patients (2.4%). The median baseline NIHSS score was 23 (IQR 12-30) and median PC-ASPECTS was 9 (IQR 7-10). Intravenous thrombolysis was administered in 55 patients (22.1%) while general anesthesia was used in 94/248 patients (37.9%). The median time from onset to puncture time was 320 minutes (IQR 215-496), with a median procedure time of 130 minutes (IQR 89-170). A median number of passes was 1 (IQR 1-2) and successful reperfusion was achieved in 209/249 patients (83.9%). Favorable clinical outcome (90-day mRS 0-3) was achieved in 99/246 patients (40.2%), with mortality affecting 98/246 patients (39.8%). The 24 h post procedural sICH was found in 19/247 patients (7.7%). At 1-year, favorable clinical outcome (mRS 0-3) was achieved in 98/237 patients (41.4%), with mortality affecting 113/236 patients (47.9%). Conclusion: EVT seems to be a safe and effective approach for posterior circulation tandem occlusions. More comparative studies are needed to confirm these results.

Total Basilar Artery Thrombosis Presenting with Recurrent Transient Ischemic Attacks (TIAs): A Case Report

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: Managing acute ischemic stroke in patients with significant comorbidities, such as hypertension, heart failure, and substance abuse, presents unique challenges. Timely intervention is critical, but the risk of complications and poor prognosis is high.&lt;br /&gt;&lt;strong&gt;Case Presentation&lt;/strong&gt;: A 46-year-old male with a history of smoking, drug abuse, poorly controlled hypertension, and dilated cardiomyopathy with an ejection fraction of 25%-30% presented with sudden left-sided weakness, facial droop, and dysarthria. The initial National Institutes of Health Stroke Scal score was 6. Computed tomography (CT) brain showed no acute infarctions but revealed chronic lacunar infarctions and atrophy. CT angiography identified significant vascular abnormalities, including right internal carotid artery attenuation and non-visualization of both intracranial vertebral and basilar arteries. Intravenous thrombolysis (tPA) led to initial improvement, but recurrent strokes or transient ischemic attacks (TIAs) followed, leading to intubation and mechanical ventilation. Magnetic resonance imaging revealed evolving infarctions in the pons and cerebellum. A basilar artery thrombectomy was successfully performed, but postoperative complications included spontaneous pneumothorax and femoral artery pseudoaneurysm, requiring further interventions. Due to extensive posterior circulation infarction, the patient had a poor neurological prognosis and was placed on do not resuscitate status.&lt;br /&gt;&lt;strong&gt;Conclusion&lt;/strong&gt;: This case highlights the complexities of treating acute ischemic stroke in patients with substantial comorbidities. While interventions such as thrombolysis and thrombectomy are critical, they carry risks. A multidisciplinary approach is necessary to balance immediate treatment with considerations of long-term prognosis and quality of life.&amp;nbsp;&lt;/p&gt;

Association Between Vertebral Arterial Tortuosity and Aneurysm Growth in Intracranial Vertebral Artery Dissection.

An intracranial vertebral artery dissecting aneurysm (iVADA) increases the risk of future subarachnoid hemorrhage, which is a severe complication with high rebleeding rates and poor outcomes. Identifying potential risk factors associated with iVADA growth is crucial for their effective management. This observational study was carried out at a single center and included patients who had been diagnosed with iVADA based on neuroimaging findings. We divided the patients into two groups: with and without iVADA growth. Growth was defined as any enlargement of a dilated region or a morphological change in follow-up imaging. We measured the vertebral artery tortuosity index (VTI) in the contralateral vertebral artery (VA), defined as its actual length divided by its straight length. We investigated the factors associated with iVADA growth. This study included 124 patients. The median follow-up period was 7 months. We observed iVADA growth in 54 patients (43.5%), who were more likely to be current smokers (33.3% vs. 14.3%, p=0.012) and have a higher VTI (1.14±0.11 [mean±standard deviation] vs. 1.06±0.12, p=0.035) compared with those without iVADA growth. A multivariate analysis revealed that the VTI (adjusted odds ratio=28.490, 95% confidence interval=1.025-792.046, p=0.048) was independently associated with iVADA growth. This study has identified an independent association between VA tortuosity and iVADA growth.

Clinical and Angiographic Outcomes of Endovascular Treatment for Acute Intracranial Vertebral Artery Dissecting Aneurysms Using Double-Overlapping Stents : Low-Profile Visualized Intraluminal Support within Enterprise Stents.

The use of reconstructive treatment with a double-overlapping stents has proven to be effective and safe in the current treatment of intracranial vertebral artery dissecting aneurysms (VADAs). We employed a combination of overlapping stents, using low-profile visualized intraluminal support (LVIS) within the Enterprise stent. This combination was chosen to minimize the outward bulging of the inner LVIS by overlapping it with the Enterprise stent while maintaining flow diversion and stability. This study aimed to evaluate the clinical and angiographic outcomes following the use of double-overlapping stents with LVIS within the Enterprise stent for the treatment of VADAs. From March 2016 to January 2022, total 28 patients with unruptured VADAs were treated with the double-overlapping stent technique using LVIS within an Enterprise stent in our institute. The Enterprise stent was deployed first, followed by the LVIS stent. Patient clinical and angiographic characteristics, procedural complications, and follow-up outcomes were retrospectively reviewed. All 28 patients (18 males and 10 females) were successfully treated with double-overlapping stent deployment. There were no procedural complications or new neurological deficits in any patient. Of the 28 patients, four VADAs had posterior inferior cerebellar artery involvement. Procedure-related parent artery occlusion did not occur during the angiographic follow-up conducted 6 to 12 months after the procedure. Out of 28 patients, 24 showed complete healing, three had focal residual stenosis or dilatation with residual sac and only one had a residual dissecting flap with aneurysm. All patients, including the four patients, did not require any additional procedures. The postoperative modified Rankin scale scores were 0-1 for all patients. A double-overlapping stent, with a flow-diversion effect, is a safe and effective treatment for patients with VADAs. In particular, when using the LVIS stent within an Enterprise stent, it minimizes the bulging of the inner LVIS stent while maintaining flow diversion and stability. Therefore, both can be effectively utilized as overlapping stents.

Efficacy and predicting factors of multimodal treatment for ruptured intracranial vertebral artery dissecting aneurysms.

We aimed to investigate the efficacy of our multimodal strategies and propose a treatment algorithm for ruptured vertebral artery dissecting aneurysms (VADAs). This study included 41 patients treated at a single institution between 2015 and 2022. The treatment modalities were justified based on the collateral circulation and aneurysm location related to the posterior inferior cerebellar artery (PICA). Treatment outcomes and complications of each treatment group were analyzed. The association between the collateral blood flow and the postoperative vertebrobasilar ischemia (VBI) was also investigated. There were 17 post-PICA, 10 PICA-involved, 7 pre-PICA, and 7 non-PICA types. Reconstruction techniques included flow diversion devices (n = 11) and stent-assisted coiling (n = 3). Deconstruction techniques included coil trapping (n=17) and microsurgical parent artery occlusion with (n = 8) or without PICA revascularization (n = 2). Five (18.5%) of the deconstruction group had postoperative VBI. Overall favorable outcomes in both groups were observed in 70.7% of patients with a mean follow-up time of 21.5 months. Poor World Federation of Neurosurgical Societies grade (IV-V) was identified as a predictor of unfavorable outcomes (p = 0.003). In addition, the VA4/BA4 ratio > 0.22, the presence of collateral blood flow from the posterior communicating artery (PcomA), and a contralateral VA diameter > 2.5 mm were associated with a lower risk of postoperative VBI. In summary, the proposed strategic treatment in this study is pragmatic, yielding satisfactory results where a deconstructive technique should be used with caution, particularly when there is a flow mismatch or the absence of collateral PcomA in the vertebrobasilar circulation.

A Comparative Study of the Etiology of Intracranial Vertebral Artery Dissection and Carotid Artery Dissection.

Both extrinsic (trauma or violent movement) and intrinsic (structural abnormality, atherosclerosis, or hemodynamic instability) factors may result in arterial dissection. The role of these factors in the origin or progression of dissection remains unclear. This study aimed to characterize the clinical features, radiologic features, and outcomes of intracranial vertebral artery dissection compared with carotid artery dissection and to determine the major causative factors. Consecutive patients with craniocervical dissection (n=127) were retrospectively analyzed. Patients with intracranial vertebral artery dissection (n=77) and those with carotid artery dissection (n=35) were compared with respect to patient age, sex, cerebrovascular risk factors, laboratory indices, and radiologic features. Intracranial vertebral artery dissection was the most common craniocervical arterial dissection in our cohort (n=77, 60.6%). Body mass index in the intracranial vertebral artery dissection group was significantly greater than that in carotid artery dissection group. Clinical manifestations of intracranial vertebral artery dissection included ischemic stroke (37.7%), dizziness or vertigo (39.0%), and headache or neck pain (44.2%). Two patients had a definite history of trauma. The frontal and lateral tortuosity ratios of the vertebral basilar artery were significantly greater while the vertex angle was smaller in the intracranial vertebral artery dissection group compared with carotid artery dissection group. A positive correlation between the tortuosity ratios and subarachnoid hemorrhage and a significant inverse correlation between the tortuosity ratios and lipid parameters (high-density lipoprotein; apolipoprotein A1) were identified. Intrinsic causes may play a more important role in the development of intracranial vertebral artery dissection than carotid artery dissection.

Safety and efficacy of enterprise stenting for symptomatic atherosclerotic severe posterior circulation stenosis

PurposeTo investigate the safety and efficacy of Enterprise stent angioplasty and risk factors for the prognoses in treating symptomatic severe posterior circulation atherosclerotic stenosis (SSPCAS).Materials and methodsPatients with SSPCAS who were treated with the Enterprise stent angioplasty were retrospectively enrolled. The clinical data, peri-procedural complications, postoperative residual stenosis, in-stent restenosis and recurrent stroke at follow-up were analyzed.Results262 patients with 275 stenotic lesions treated with the Enterprise stent angioplasty were enrolled. The stenosis degree was reduced from 86.3 ± 6.2% before to 19.3 ± 5.4% after stenting. Complications occurred in 14 (5.3%) patients. Clinical follow-up was performed in 245 (93.51%) patients for 16.5 ± 7.3 months. During 1 year follow-up, 7 patients (2.9%) had recurrent symptoms, including 4 patients with stenting in the intracranial vertebral artery and 3 in the basilar artery. Imaging follow-up was conducted in 223 (85.11%) patients. In-stent restenosis was present in 35 patients (15.7%), with the restenosis rate of 26.4% (n = 23) in the intracranial vertebral artery, which was significantly (P < 0.001) greater than in the basilar artery (8.8%). Six patients (17.1%) with in-stent restenosis were symptomatic. The stenotic length was the only significant (P = 0.026 and 0.024, respectively) independent risk factor for 1 year stroke or death events and in-stent restenosis.ConclusionThe Enterprise stent can be safely and efficaciously applied in the treatment of symptomatic severe posterior circulation atherosclerotic stenosis, with a relatively low rate of in-stent restenosis and recurrent stroke within 1 year. The stenotic length was the only significant independent risk factor for 1 year stroke or death events and in-stent restenosis.

Imaging features of vertebrobasilar dolichoectasia combined with posterior circulation ischemic stroke: A vessel wall magnetic resonance imaging study

PurposeTo elucidate the vessel wall changes of vertebrobasilar dolichoectasia (VBD) with ischemic stroke, using vessel wall magnetic resonance imaging (VW-MRI). MethodThirty-four patients with VBD (22 with stroke and 12 without stroke) who underwent VW-MRI were recruited. Forty-one patients without VBD who underwent VW-MRI were also recruited if they had a recent stroke due to atherosclerosis in the basilar artery or the intracranial vertebral artery. The vessel wall features of VBD were compared between stroke and non-stroke groups. The plaque characteristics were compared between VBD and non-VBD stroke patients. ResultsThe frequency of plaques was higher (54.5% vs. 8.3%, P = 0.011) in VBD patients with stroke than that in non-stroke patients, while the frequencies of aneurysm, dissection, intraluminal thrombus, and diffuse/concentric wall enhancement did not differ. When the plaque features were compared between plaque-positive stroke patients with and without VBD, the degree of stenosis (31.0% ± 26.8% vs. 71.5% ± 19.0%, P < 0.001), normalized wall index (NWI) (0.7 ± 0.1 vs. 0.9 ± 0.1, P < 0.001), and remodeling index (RI) (1.0 ± 0.4 vs. 1.3 ± 0.4, P = 0.023) were lower in the VBD group, while intraplaque hemorrhage, and enhancement ratio showed no difference. ConclusionsThis preliminary study suggests that atherosclerosis may be an important cause of stroke in VBD patients. Symptomatic plaques in VBD patients have a lower degree of stenosis, NWI, and RI than that in non-VBD patients. VW-MRI may help to assess stroke mechanisms and identify VBD patients at high risk.

Treatment of Intracranial Vertebral Artery Dissecting Aneurysms Using Pipeline Embolization Devices : AMulticenter Cohort Study.

Intracranial vertebral artery dissecting aneurysm (IVADA) is arare type of aneurysm with high morbidity and mortality. Recently, the application of pipeline embolization devices (PEDs) has been extended to IVADAs. Here, we aim to investigate the safety and effectiveness of PEDs for IVADAs. We retrospectively reviewed the PLUS database to identify patients who had IVADAs and were treated with PEDs from 2014 to 2019 at 14centers across China. Data including patient and aneurysm characteristics, procedure details, angiographic and clinical results, relationship with the ipsilateral posterior inferior cerebellar artery (PICA), and patency of the PICA following PED coverage were analyzed. In this study 52 consecutive patients with 52IVADAs were included. The mean age was 52.33years and 82.7% were male. With amedian follow-up of 10.5months, the complete occlusion rate was 93.8% (45/48) and no recurrence or in-stent stenosis was detected. The total postoperative complication rate and mortality were 11.5% and 1.9%, respectively. Complications occurred in 9.6% (5/52) of patients within 30days after the operation, including ischemic stroke in3 and hemorrhagic stroke in2. Another patient suffered an ischemic stroke at follow-up, 78.8% (41/52) PICAs were covered by PEDs, 1 case (2.4%) had afunctional disability due to PICA occlusion, while 39.0% (16/41) had reduced flow during follow-up but hardly caused any obvious neurological deficits. Patients with IVADA involving PICA had atrend towards more complications (66.7% vs. 51.1%; P = 1). Treating IVADAs with PEDs may be asafe and effective option, with favorable clinical and angiographic outcomes; however, complications associated with this treatment should not be ignored. http://www. gov . Unique identifier: NCT03831672.

Thrombectomy with or without Intravenous Thrombolytics in Basilar Artery Occlusion.

Two randomized trials demonstrated the benefit of endovascular therapy (EVT) in patients suffering from a stroke due to a basilar artery occlusion (BAO). However, intravenous thrombolytic (IVT) use before EVT was low in these trials, questioning the added value of this treatment in this setting. We sought to investigate the efficacy and safety of EVT alone compared to IVT + EVT in stroke patients with a BAO. We analyzed data from the Endovascular Treatment in Ischemic Stroke registry, a prospective, observational, multicenter study of acute ischemic stroke patients treated with EVT in 21 centers in France between 1 January 2015 and 31 December 2021. We included patients with BAO and/or intracranial vertebral artery occlusion and compared patients treated with EVT alone versus IVT + EVT after propensity score (PS) matching. Variables selected for the PS were pre-stroke mRS, dyslipidemia, diabetes, anticoagulation, admission mode, baseline NIHSS and ASPECTS, type of anesthesia, and time from symptom onset to puncture. Efficacy outcomes were good functional outcome (modified Rankin Scale [mRS] 0-3) and functional independence (mRS 0-2) at 90 days. Safety outcomes were symptomatic intracranial hemorrhages and all-cause mortality at 90 days. Among 385 patients, 243 (134 EVT alone and 109 IVT + EVT) were included after PS matching. There was no difference between EVT alone and IVT + EVT regarding good functional outcome (adjusted odd ratio [aOR] labeling = 1.27, 95% confidence interval [CI], 0.68-2.37, p = 0.45) and functional independence (aOR = 1.50, 95% CI, 0.79-2.85, p = 0.21). Symptomatic intracranial hemorrhage and all-cause mortality were also similar between the two groups (aOR = 0.42, 95% CI, 0.10-1.79, p = 0.24 and aOR = 0.56, 95% CI, 0.29-1.10, p = 0.09, respectively). In this PS matching analysis, EVT alone seemed to lead to similar neurological recovery than IVT + EVT, with comparable safety profile. However, given our sample size and the observational nature of this study, further studies are needed to confirm these findings. ANN NEUROL 2023.

Flow Diverter Treatment Using a Flow Re-Direction Endoluminal Device for Unruptured Intracranial Vertebral Artery Dissecting Aneurysm: Single-Center Case Series and Technical Considerations.

This study aimed to evaluate the effectiveness, safety, and technical considerations of flow diverter (FD) treatment using a Flow Re-direction Endoluminal Device (FRED) for unruptured intracranial vertebral artery dissecting aneurysms (VADAs). We conducted a retrospective study of 23 patients with unruptured intracranial VADAs who underwent FD treatment using a FRED between June 2017 and August 2021. Symptoms, imaging findings, treatment strategies, and angiographic and clinical outcomes were evaluated. Dissections were categorized according to the dominance of the VA in which they occurred: dominant VA, co-dominant VA, and non-dominant VA. All patients successfully underwent FD treatment with either a FRED (n=11) or FRED Jr. (n=12). Complete occlusion rates were 78.3% at 6-month follow-up magnetic resonance angiography and 91.3% at 12-month. There were no instances of complications, recurrence, or retreatment during a median follow-up of 20 months. Dissections occurred in the dominant VA in 3 cases (13.0%), the co-dominant VA in 13 cases (56.5%), and the non-dominant VA in 7 cases (30.4%). Intimal flap and true lumen stenosis were observed in 39.1% and 30.4% of cases, respectively. Four cases required a bilateral VA approach due to technical difficulties, all in the non-dominant VA. Flow diversion treatment using a FRED for unruptured intracranial VADAs proved feasible and safe, yielding satisfactory occlusion rates. Technical challenges were more likely in lesions involving non-dominant VAs in the acute or subacute stage, mainly due to associated intraluminal lesions compromising the arterial lumen.

Association between the degree of vertebrobasilar stenosis, location, infarction pattern, and QMRA flow state.

We aimed to investigate the relationship between the degree and location of vertebrobasilar stenosis and quantitative magnetic resonance angiography (QMRA) distal flow. We retrospectively reviewed patients who presented with acute ischemic stroke with ≥50% stenosis of the extracranial or intracranial vertebral or basilar arteries, and QMRA performed within 1year of stroke. Standardized techniques were used to measure stenosis and to dichotomize vertebrobasilar distal flow status. Patients were grouped based on the involved artery and the severity of disease. All p-values were calculated using chi-squared analysis and Fisher exact test with statistical significance defined as p<.05. Sixty-nine patients met study inclusion, consisting of 31 with low distal flow and 38 with normal distal flow. The presence of severe stenosis or occlusion was 100% sensitive, but only 47% predictive and 26% specific of a low distal flow state. Bilateral vertebral disease was only 55% sensitive but was 71% predictive and 82% specific of a low-flow state and was five times and nearly three times more likely to result in a low-flow state compared to unilateral vertebral disease (14%) and isolated basilar disease (28%), respectively. Severe stenosis of ≥70% may mark the minimal threshold required to cause hemodynamic insufficiency in the posterior circulation, but nearly half of these patients may remain hemodynamically sufficient. Bilateral vertebral stenosis resulted in a fivefold increase in QMRA low distal flow status compared to unilateral vertebral disease. These results may have implications in the design of future treatment trials of intracranial atherosclerotic disease.

Primary Antiphospholipid Syndrome Presenting with Cerebellar Stroke and Positive Titres of Anti-β2 Glycoprotein-1 Antibody Only: A Case Report (P9-5.026)

<h3>Objective:</h3> To describe a case of Primary Antiphospholipid Syndrome presenting with Cerebellar Stroke and positive titres of anti-β2 glycoprotein-1 antibody only. <h3>Background:</h3> Antiphospholipid syndrome (APS) is an autoimmune disease where the presence of antiphospholipid antibodies leads to the development of arterial and/or venous thromboses and obstetric complications. Amongst the myriad of presentations, APS can manifest in the form of cerebrovascular stroke. However, overlapping clinico-radiological findings and a lack of classic APS features can sometimes pose a diagnostic dilemma. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 31-year-old female presented with occipital headache and difficulty in walking. Neurological examination revealed ataxia, dysdiadochokinesia and intention tremor. Preliminary laboratory findings revealed raised ESR along with normal CRP, aPTT and PT levels. MRI brain showed an acute infarct in the right cerebellar hemisphere and right postero-lateral upper medulla. MRA Head &amp; Neck revealed an occluded intracranial right vertebral artery with an extracranial segment showing multifocal occlusions with aorta and its major branches unaffected. These features and the absence of fever, rash, joint pain or obstetric complications led to the consideration of stroke due to Takayasu Arteritis. Treatment was initiated with corticosteroids, anticoagulants and antiplatelet drugs. However, on review of other laboratory tests, notably the auto-immune profile showed the presence of anti-ß2 glycoprotein-I antibodies with negligible titres of lupus anticoagulant and anti-cardiolipin antibody. This pointed towards a diagnosis of Primary Antiphospholipid Syndrome, which was confirmed after 12 weeks when repeat laboratory tests indicated the presence of IgM anti-ß2 glycoprotein-I antibodies. The patient is now on lifelong Warfarin therapy and is leading a symptom-free life. <h3>Conclusions:</h3> This case illustrates the potential of anti-β2 glycoprotein-1 antibody to cause a cerebellar stroke in the absence of other commonly involved antibodies. It also highlights the value of a holistic stroke workup. Recognition of APS is imperative for the timely administration of treatment and to prevent a recurrence. <b>Disclosure:</b> Mr. Shah has nothing to disclose. Mr. Shah has nothing to disclose. Dr. Nagrani has nothing to disclose.

Spinal Cord Ischemia in a Young Patient Following Strenuous Exercise (P6-5.027)

<h3>Objective:</h3> NA <h3>Background:</h3> Spinal infarcts in the setting of anatomical variants with absent arteries of Lazorthes and Adamkiewicz are rare and seldom reported. <h3>Design/Methods:</h3> We report a healthy twenty-two-year-old man who presented after severe neck pain following strenuous weight lifting, with bilateral arm followed by leg weakness, and respiratory failure requiring intubation. Initial exam was significant for absent movement in the arms and decreased movement in the left &gt; right leg, a C3 sensory level, and hyporeflexia. MRI cervical/thoracic/lumbar spine with and without gadolinium revealed an extensive, thin, anterior, non-enhancing T2 hyperintensity from the craniocervical junction to T7. CSF analysis was unremarkable. He was started on steroids and plasmapheresis for possible NMOSD though anterior spinal artery infarct was high in the differential. Repeat MRI was DWI positive with ADC correlate. A spinal angiogram revealed the absence of intracranial vertebral artery, PICA, a. of Lazorthes, and a. of Adamkiewicz. Steroids and plasmapheresis were discontinued after anti-MOG and NMO antibodies were negative. <h3>Results:</h3> This patient’s presentation exemplifies the challenge of determining whether the underlying etiology is demyelinating versus ischemic. Given that the patient’s symptoms developed in the setting of strenuous weight lifting, the diagnosis of spinal cord infarct is likely. The most probable mechanism is dissection and occlusion of the vertebral artery with subsequent occlusion of the anterior spinal artery. The anatomic variants seen in the spinal angiogram may have worsened the presentation due to fewer collaterals present. Another mechanism which was considered, although less likely, was fibrocartilaginous embolism. During the hospital course the patient regained motor function in the legs and some function in the arms but continued to require mechanical ventilation. <h3>Conclusions:</h3> Acute intramedullary ischemia should be considered in younger patients without vascular risk factors if the clinical presentation and diagnostic work-up are suggestive, even when a thrombus or dissection is not seen on angiogram. <b>Disclosure:</b> Dr. Bellara has nothing to disclose. Dr. Sacks has nothing to disclose. Dr. Choi has nothing to disclose. Dr. Chernyak has nothing to disclose. Dr. Jacoby has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion. Dr. Jacoby has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Argenx. Dr. Jacoby has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for N/A. The institution of Dr. Jacoby has received research support from ABPN. Dr. Levine has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for MEDLINK. Dr. Levine has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for Law Firms. The institution of Dr. Levine has received research support from NIH.