Intracranial Vertebral Artery Stenosis Research Articles

Abstract 1122‐000027: Bilateral Vertebral Artery Occlusion and Involvement of the Posterior Circulation

Introduction : Rationale: Bilateral vertebral artery occlusion with collateral reconstitution is a rare finding. Compared to patients with acute occlusion, symptom progression may be much slower [1]. Atherosclerotic risk factors lead to occlusion, including hypertension and hyperlipidemia, but it is unclear what leads to collateral reconstitution [2]. These patients may have collateral circulation from anterior and posterior circulation sources that are well developed [1] [2]. Sufficient collateral flow correlates with lower rates of hemorrhagic transformation following recanalization [3] [4]. However, given the risk of spontaneous hemorrhage from microvascular collaterals, the hemorrhagic risk associated with thrombolytic therapy in patients with moyamoya collaterals, due to the fragility of these vessels [5], must be balanced with the benefit of therapy in the presence of severe neurologic deficits along with the mortality and morbidity that may stem from the occlusion. Patient concerns: 67 year old Caucasian male with past medical history of coronary artery disease, abdominal aortic aneurysm, hypertension, history of tobacco use and type 2 diabetes mellitus presents with acute right‐sided weakness. Methods : Diagnoses: On admission, CTA Head and Neck suggested chronic total occlusion of bilateral V4 segments from their origin to the midportion with tandem bilateral high‐grade stenoses throughout the imaged distal V2 and V3 segments bilaterally. MRI could not be obtained because of old lumbar fusion spinal hardware. Cerebral angiography showed microvascular reconstitution, analogous to moyamoya, with slow mid basilar flow, which could be either due to occlusion or competitive flow from top of the basilar collaterals. Interventions: Patient received intra‐arterial integrilin and tPA thrombolysis with TICI 1 reperfusion. Results : Outcomes: Patient presented with NIHSS 18 notable for right sided weakness (2/5 strength in his right upper extremity and 1/5 strength in RLE), bilateral hemianopia, severe dysarthria and right gaze preference. Patient had significant improvement in his exam the next day following thrombolysis. Notably, patient had 5/5 strength in his right upper and right lower extremities compared to his strength on presentation. Repeat head CT on the following day after thrombolysis showed left pontine infarct. Repeat NIHSS was 3 at 24 hours for partial hemianopia, minor nasolabial flattening and mild dysarthria. Conclusions : Conclusion: Bilateral intracranial vertebral artery stenosis and occlusion commonly occurs distal to PICA and near the vertebrobasilar junction [2]. Proximal (specifically areas supplied by PICA) and distal territories within the posterior circulation are often infarcted [2], which can yield a unique exam upon presentation that can help accurately guide diagnosis and treatment when appropriately recognized. The involvement of collateral circulation can play a crucial role in patients undergoing endovascular revascularization therapy [6]. In the setting of bilateral vertebral occlusion with microvascular reconstitution, patients can still undergo catheter based thrombolysis, but not thrombectomy.

Transradial approach using a distal access catheter without guiding support for symptomatic intracranial vertebral artery and basilar artery stenosis: a multicenter experience and technical procedure

BackgroundThere is little consensus on endovascular treatment for symptomatic intracranial posterior circulation stenosis via the transradial approach (TRA). We report our multicenter experience and technical procedures that directly used a...

Management of intracranial vertebral artery stenosis with ipsilateral vertebral artery hypoplasia and contralateral vertebral artery occlusion via type 2 proatlantal intersegmental artery

BackgroundProatlantal intersegmental artery (PIA) is a rare primitive carotid-basilar anastomosis. PIA may accompany with ipsilateral or bilateral vertebral arteries (VAs) agenesis. Here, we presented the case with intracranial VA stenosis supplying via PIA and demonstrated how we evaluated and managed. MethodsDual antiplatelet therapy and adequate hydration were given for three weeks for intracranial atherosclerotic disease (ICAD). We arranged magnetic resonance (MR) vessel wall imaging to survey both intracranial VAs. Intracranial right VA stenosis supplying via PIA with ipsilateral VA hypoplasia and contralateral intracranial VA occlusion caused multiple posterior circulation infarcts. We performed angioplasty and intracranial stenting for ICAD at the right VA V4 segment via PIA. ResultsNational Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) got improved at discharge and ten months. ConclusionsThis case is the first report for ICAD management via PIA. A persistent type 2 PIA is essential for supplying posterior circulation.

Stenting for Symptomatic Intracranial Vertebrobasilar Artery Stenosis in Northeast of China: A Single-Center Study.

Objective: We described the incidence of surgery-related complications to evaluate the safety of endovascular therapy for severe symptomatic intracranial vertebral basilar artery stenosis (IVBS) in our stroke center in Northeast of China.Methods: Consecutive patients with symptomatic IVBS caused by 70–99% stenosis despite standard medical treatment of antiplatelet agents plus statin were enrolled. Either balloon-mounted stent or balloon predilation plus self-expanding stent was performed. Clinical adverse events such as stroke, transient ischemic attack (TIA), and death after the surgery were documented. Radiological events such as in-stent thrombosis, dissection, and guide-wire perforation during the process were recorded as complications as well. The baseline characteristics and outcomes of patients among different Mori types were compared.Results: From January 2017 to December 2018, 97 patients with stroke or TIA due to intracranial IVBS were treated by stenting, including 30 patients with basilar artery (BA) stenosis, 55 patients with intracranial vertebral artery (V4) stenosis, and 12 patients with V4-BA stenosis. The primary events include two intracranial hemorrhage (2.1%, 2/97), seven ischemic events (7.2%, 7/97), and two death (2.1%, 2/97). The successful stent deployment rate was 98.9% (96/97). The Apollo stents were used more for Mori A lesions. Self-expanding stents were more used in Mori C lesions. Mori C lesions were more vulnerable to endovascular procedure and showed higher rate of complications than A (p = 0.008) and B type (p = 0.047).Conclusion: A high technical success rate of IVBS stenting could be achieved, and the safety was acceptable, whereas Mori C lesions were more vulnerable to endovascular procedure and showed a higher rate of complications than A and B types.

Correlation between intracranial vertebral artery stenosis diameter measured by digital subtraction angiography and cross-sectional area measured by optical coherence tomography

BackgroundIntracranial vertebral artery (V4 segment) stenosis quantification traditionally uses the narrowest stenosis diameter. However, the stenotic V4 lumen is commonly irregularly shaped. Optical coherence tomography (OCT) allows a more precise...

Vertebral Artery Stenosis

Vertebral artery stenosis is a common condition associated with a very high risk of stroke. The goal of this review is to summarize the pathophysiology and natural history of vertebral artery stenosis and to evaluate the efficacy of medical and endovascular therapies. Early and aggressive initiation of medical care combined with advancements in antithrombotic and lipid-lowering therapies has substantially reduced the risk of stroke due to vertebral artery stenosis. Endovascular therapy does not appear to be beneficial with extracranial vertebral artery stenosis and appears harmful with intracranial vertebral artery stenosis. Risk of stroke due to symptomatic vertebral artery stenosis can be significantly reduced with implementation of standardized best medical therapy protocols focusing on ultra-early dual antiplatelet therapy, high-intensity statin therapy + novel lipid-lowering agents, and aggressive risk factor control. Endovascular therapy with angioplasty and stenting is not likely to play a significant role in treatment.

Correlation between the hemodynamic parameters of extracranial vertebral artery and the severity and location of intracranial vertebral artery stenosis

Objective To analyze the effects of the degree and location of intracranial vertebral artery(VA) lesions on the hemodynamic parameters of extracranial VA. Methods A total of 275 consecutive patients who were diagnosed as posterior circulation ischemic stroke or transient ischemic attack (TIA) with unilateral intracranial VA stenosis or occlusion in the Department of Neurology and Neurosurgery of Capital Medical University Xuanwu Hospital from January 2015 to December 2017 were enrolled. All patients were examined by head and neck vascular ultrasound, CT angiography (CTA) and/or digital subtraction angiography (DSA) within one week. According to the results of DSA or CTA, the patients were divided into mild stenosis group(53 patients), moderate stenosis group(62 patients), severe stenosis group(58 patients) and occlusion group(102 patients). The inner diameter (D), peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) of the extracranial segment (V2 segment) of the VA were recorded and analyzed. Results The PSV and EDV in the severe stenosis group and the occlusion group were significantly lower than those in the mild stenosis group and the moderate stenosis group (P=0.000), and the PSV and EDV in the occlusion group were significantly lower than those in the severe stenosis group[ (31±10) cm/s vs (46±12)cm/s, (5±4)cm/s vs (15±7)cm/s; all P=0.000], RI was significantly higher than the other three groups (0.85±0.12, 0.70±0.10, 0.66±0.07, 0.64±0.06, respectively; all P=0.000); RI in the severe stenosis group were not significantly different from those in the mild to moderate stenosis groups (P=0.044, 0.223). There were no significant differences in the inner diameter, PSV, EDV and RI between the subgroups in the severe stenosis group before or after the PICA (posterior inferior cerebellar artery)(P=0.130, 0.322, 0.865, 0.227). However, the EDV decreased and RI increased in the occlusive subgroup before the PICA when compared the subgroup after the PICA (all P=0.000). Conclusions The location and degree of intracranial VA lesions directly affect the changes of blood flow velocity and vascular resistance of extracranial VA, and the changes of low-speed and high-resistance hemodynamics of extracranial VA may indicate the existence of occlusive lesions in intracranial VA. Key words: Ultrasonography; Vertebral artery stenosis; Occlusive diseases; Hemodynamics; Extracranial segment; Intracranial segment

Endovascular treatment of patients with high-risk symptomatic intracranial vertebrobasilar stenoses: long - term outcomes

Background and purposeWe present the long-term outcome after endovascular treatment of symptomatic intracranial posterior circulation stenoses.Methods30 patients with symptomatic intracranial posterior circulation stenoses exceeding 70% underwent endovascular treatment between 2006...

Advances in endovascular therapy for ischemic cerebrovascular diseases

Endovascular therapy for ischemic cerebrovascular diseases has developed rapidly in recent years. The latest clinical trials of acute ischemic stroke have shown promising results with the continued advancement of concepts, techniques, and materials. Mechanical thrombectomy is recommended in the treatment of acute ischemic stroke caused by large vessel occlusion of the anterior circulation, according to the guidelines updated in Europe, USA, and China. The long-term therapeutic efficacy of endovascular stenting for carotid artery stenosis has also been proved noninferior to that of carotid endarterectomy. However, the latest clinical trials have shown that the efficacy of stenting for intracranial artery and vertebral artery stenosis is inferior to that of medical treatment alone, which needs urgent attention through further development and studies.

Evaluation of Interventional Therapy for Patients with Intracranial Vertebral Artery Stenosis by Transcranial Color-Coded Sonography

The aim of this study was to evaluate the efficacy of stenting for patients with intra-cranial vertebral artery stenosis by trans-cranial color-coded sonography and to analyze the risk factors of in-stent restenosis (ISR). In total, 121 patients with intra-cranial vertebral artery stenosis stents were included. The follow-up time was 3–12 mo (mean: 9.9 mo). The success rate was 92.6%. Peak systolic velocity and end-diastolic velocity decreased from 261 ± 63 to 109 ± 41 cm/s and from 133 ± 44 to 47 ± 18 cm/s, respectively (both p < 0.001). Peak systolic velocity (245 ± 47 cm/s) and end-diastolic velocity (121 ± 31 cm/s) of patients with ISR (18.9%, 20/106) were higher than those of patients without ISR (101 ± 38 and 44 ± 17 cm/s, respectively) at 12 mo post-procedure (p < 0.05). The length of the stent and residual stenosis were related to ISR. In conclusion, stenting is a feasible treatment method for intra-cranial vertebral artery stenosis. Trans-cranial color-coded sonography can be used for monitoring patients to identify ISR.

Stenting versus medical treatment in patients with symptomatic vertebral artery stenosis: a randomised open-label phase 2 trial

Patients with a recent vertebrobasilar transient ischaemic attack or ischaemic stroke and vertebral artery stenosis of at least 50% have a high risk of future vertebrobasilar stroke. Stenting of vertebral artery stenosis is promising, but of uncertain benefit. We investigated the safety and feasibility of stenting of symptomatic vertebral artery stenosis of at least 50%, and assessed the rate of vascular events in the vertebrobasilar supply territory to inform the design of a phase 3 trial. Between Jan 22, 2008, and April 8, 2013, patients with a recent transient ischaemic attack or minor stroke associated with an intracranial or extracranial vertebral artery stenosis of at least 50% were enrolled from seven hospitals in the Netherlands in a phase 2 open-label trial with masked assessment of outcome. Patients were randomly allocated in a 1:1 ratio to stenting plus best medical treatment or best medical treatment alone by the local investigators using a web-based randomisation system. The primary outcome was the composite of vascular death, myocardial infarction, or any stroke within 30 days after the start of treatment. The secondary outcomes were stroke in the supply territory of the symptomatic vertebral artery during follow-up, the composite outcome during follow-up, and the degree of stenosis in the symptomatic vertebral artery at 12 months. The trial is registered, number ISRCTN29597900. The trial was stopped after inclusion of 115 patients because of new regulatory requirements, including the use of a few prespecified stent types and external monitoring, for which no funding was available. 57 patients were assigned to stenting and 58 to medical treatment alone. Three patients in the stenting group had vascular death, myocardial infarction, or any stroke within 30 days after the start of treatment (5%, 95% CI 0-11) versus one patient in the medical treatment group (2%, 0-5). During a median follow-up of 3 years (IQR 1·3-4·1), seven (12%, 95% CI 6-24) patients in the stenting group and four (7%, 2-17) in the medical treatment group had a stroke in the territory of the symptomatic vertebral artery; 11 (19%) patients in the stenting group and ten (17%) in the medical treatment group had vascular death, myocardial infarction, or any stroke. The small size of the vertebral artery and stent artifacts did not allow exact grading of restenosis on CT angiography. During the complete period of follow-up, there were 60 serious adverse events (eight strokes) in the stenting group and 56 (seven strokes) in the medical treatment alone group. Stenting of symptomatic vertebral artery stenosis is associated with a major periprocedural vascular complication in about one in 20 patients. In the population we studied, the risk of recurrent vertebrobasilar stroke under best medical treatment alone was low, questioning the need for and feasibility of a phase 3 trial. Dutch Heart Foundation.

Yet again no benefit of stenting over medical therapy

Atherosclerotic stenosis at the origin or intracranial portion of a vertebral artery is an important cause of stroke.1,2 Registry data have suggested that the risk of recurrent stroke in patients with symptomatic vertebral artery stenosis treated medically is high,1–3 which has led to the use of stenting for stroke prevention in these patients. However, evidence that stenting is better than medical therapy has been lacking. In The Lancet Neurology, Annette Compter and colleagues report the results of the phase 2 study VAST, which is the largest clinical trial for the comparison of outcomes in patients with symptomatic extracranial or intracranial vertebral artery stenosis randomly assigned to stenting versus medical treatment.

Bilateral Intracranial Vertebral Artery Stenosis Presenting as Recurrent Prolonged Presyncopal Episodes.

Amongst various mechanisms of presyncopal events, posterior circulation disease needs to be considered. This particular mechanism has been underrecognized. We describe a case of a 76-year-old patient with recurrent posterior circulation TIAs, presenting as recurrent prolonged presyncopal events.

How Healthy is Your Brand-Health Tracker?

<h3>Background</h3> Calcification has been proven to be a marker of atherosclerosis and is related to an increased risk of ischemic stroke. Additionally, calcification was reported to be prevalent in patients with stenotic lesions of the intracranial vertebral artery. Thus, reliable imaging facilities for evaluating plaque calcification have remarkable significance in guiding stenting and predicting patient outcomes. Optical coherence tomography (OCT) has a unique advantage in its ability to detect calcium and to achieve three-dimensional volumetric calcium characterization. <h3>Methods</h3> From March 2017 to September 2018, seven cases of calcified lesions with intracranial vertebral artery stenosis were investigated using OCT, before and after the placement of an Apollo balloon-mounted stent. Transcranial color-coded duplex sonography was performed to identify restenosis with a mean follow-up time of 13.3 months in this case series. <h3>Results</h3> All calcified lesions were evaluated quantitatively and qualitatively using OCT. Among all cases, five had macrocalcifications and two had spotty calcifications. Severe in-stent restenosis was observed in two cases, both with macrocalcifications. <h3>Conclusions</h3> This study suggests a potential relationship between macrocalcifications and the risk of in-stent restenosis of the intracranial vertebral artery. These preliminary findings obtained from a limited sample should be verified by prospective large-scale studies.

Bilateral IntraCranial Vertebral Artery Stenosis Presenting as Recurrent Prolonged Presyncopal Episodes (P07.272)

Bilateral IntraCranial Vertebral Artery Stenosis Presenting as Recurrent Prolonged Presyncopal Episodes (P07.272)

Dual origin of the left vertebral artery: Extracranial MRA and CTA findings

A 48-year-old man presented with a posterior circulation stroke secondary to left lateral medullary infarction. Contrast-enhanced magnetic resonance angiography (CEMRA) revealed 40–45% intracranial left vertebral artery stenosis, likely atherosclerotic in nature. CEMRA and subsequent computed tomography angiography also identified a duplicate origin of the left vertebral artery. The importance of recognition of this rare anatomical variant, its potential contribution to stroke aetiology, and the advantage of non-invasive vascular imaging prior to catheter angiography is emphasised.

Endovascular Stenting for Vertebral Artery Stenosis

The aim of this study was to demonstrate the safety and long-term durability of catheter-based therapy for symptomatic vertebral artery stenosis (VAS). Symptomatic VAS carries with it a 5-year 30% to 35% risk of stroke. The 2-year mortality approaches 30% for medically managed strokes involving the posterior circulation. Surgical bypass is rarely performed, due to high morbidity and mortality. Endovascular revascularization with primary stenting offers an attractive treatment option for these patients. One-hundred five consecutive symptomatic patients (112 arteries, 71% male) underwent stent placement for extracranial (91%) and intracranial (9%) VAS from 1995 to 2006. Fifty-seven patients (54%) had bilateral VAS, 71 patients (68%) had concomitant carotid disease, and 43 patients (41%) had a prior stroke. Procedural and clinical success was achieved in 105 (100%) and 95 (90.5%) patients, respectively. One-year follow-up was obtained in 87 (82.9%) patients, of which 69 patients (79.3%) remained symptom-free. At 1 year, 6 patients (5.7%) had died and 5 patients (5%) had a posterior circulation stroke. Target vessel revascularization occurred in 7.4% at 1 year. At a median follow-up of 29.1 months (interquartile range 12.8 to 50.9 months), 13.1% underwent target vessel revascularization, 71.4% were alive, and 70.5% remained symptom-free. In experienced hands, stenting for symptomatic VAS can be accomplished with a very high success rate (100%), with few periprocedural complications, and is associated with durable symptom resolution in the majority (approximately 80%) of patients. We conclude that endovascular stenting of vertebral artery atherosclerotic disease is safe and effective compared with surgical controls and should be considered first-line therapy for this disease.

Impaired Cognitive Function Due to Cerebellar Infarction and Improvement After Stent-Assisted Angioplasty for Intracranial Vertebral Artery Stenosis -Case Report-

A 69-year-old female presented with multiple cerebellar infarctions and mild cognitive dysfunction. Cerebral angiography revealed severe right vertebral artery (VA) stenosis just proximal to the origin of the posterior inferior cerebellar artery. Neuropsychology tests showed the mini-mental state examination (MMSE) score was 21, and the Wechsler Adult Intelligence Scale-Revised (WAIS-R) score was 70. Cerebrovascular reactivity (CVR) was decreased in the bilateral cerebral and cerebellar hemispheres. Stent-assisted angioplasty of the right VA was performed to prevent recurrence of the cerebellar infarction. Post-procedure, the neuropsychology tests showed cognitive improvement to MMSE score of 26 and WAIS-R score of 84. CVR had also improved in the bilateral cerebral hemispheres. Cerebellar hypoperfusion due to VA stenosis had probably caused functional depression of the cerebello-cerebral pathway, a condition referred to as crossed cerebello-cerebral diaschisis. In this case, cognitive dysfunction was reversed due to recovery of the cerebello-cerebral pathway.

Very late thrombosis in a patient with a drug-eluting stent for intracranial atherosclerotic stenosis

Late stent thrombosis is an infrequent, but severe, complication after implantation of a drug-eluting stent. We report one such patient, a 69-year-old man with intracranial vertebral artery stenosis. He experienced very late stent thrombosis after discontinuation of clopidogrel therapy, about 16 months after the insertion of a Taxus Stent ® (Boston Scientific Corporation, Natick, MA, USA). The patient recovered well, with good clinical outcome, after the re-initiation of dual antiplatelet and anticoagulation therapy. No abnormality within the stent was identified on a repeat angiogram taken 4 weeks after treatment re-initiation.

Catheter exchange technique for the Wingspan stent: technical note

Background and purposeThe only Food and Drug Administration-approved implant for managing intracranial stenosis is the Wingspan stent. Modification of the standard Wingspan stent delivery procedure has not been previously reported.Material...