Posterior Circulation Involvement Research Articles

An Approach to Working Up Cases of Embolic Stroke of Undetermined Source.

BackgroundFrom a therapeutic viewpoint, it is important to differentiate the underlying causes of embolism in patients with cryptogenic stroke, such as aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation. We investigated the clinical and radiological characteristics of these 3 common causes of cryptogenic embolism to develop models for decision making in etiologic workups.Methods and ResultsA total of 321 consecutive patients with acute infarcts from cryptogenic embolism were included. Patients were divided into 3 groups—aortic arch atheroma (n=40), patent foramen ovale (n=153), and paroxysmal atrial fibrillation (n=128)—based on extensive cardiologic workups. We used a multinomial logistic regression analysis to detect the clinical and diffusion‐weighted imaging factors associated with the probability of aortic arch atheroma, patent foramen ovale, and paroxysmal atrial fibrillation. Clinical and radiological features differed among the groups. The patent foramen ovale group had a healthy vascular risk factor profile and showed posterior circulation involvement compared with other groups (P<0.01). In contrast, paroxysmal atrial fibrillation–related strokes had higher initial National Institutes of Health Stroke Scale (NIHSS) scores and larger lesions than the other groups (P<0.001). The aortic arch atheroma group had clinical features similar to those of the paroxysmal atrial fibrillation group but showed small lesions scattered in multiple vascular territories (P<0.001). Multivariate regression analysis revealed that age, initial NIHSS score, lesion size (≥20 mm), multiple (≥3) lesions, and involvement of posterior circulation or multiple vascular territories differentiated the 3 groups (pseudo, R 2=0.656). The prediction ability of this model was validated in the external validation cohort (n=117, area under the curve 0.78).ConclusionsOur data indicate that patients with cryptogenic embolic stroke show distinct clinical and radiological features depending on the underlying causes.

Endovascular Therapy of Cerebral Arterial Occlusions: Intracranial Atherosclerosis versus Embolism

Treatment strategy for acute arterial occlusions due to intracranial atherosclerotic disease (IAD) may differ from those due to embolism (embolic). The aims were to differentiate and classify angiographically defined occlusion due to IAD versus embolism and identify baseline clinical factors associated with IAD-related occlusion. Acute ischemic stroke patients with large cerebral artery occlusions on computed tomography angiography who underwent transfemoral cerebral angiography for endovascular treatment were included. Patients were categorized as the embolic (no evidence of focal stenosis after recanalization) or IAD group (significant fixed focal stenosis in the occlusion site, evidenced in the final angiography or during the endovascular treatment procedure) based on transfemoral cerebral angiography findings. In total, 158 patients were included. The IAD group patients (n=24) were younger (P=.005), more often male (P<.001) and smokers (P<.001), and had a higher total cholesterol level (P=.001) than patients in the embolic group (n=134). The posterior circulation was more frequently involved in the IAD group (P=.001). Independent predictors of IAD on multivariable analysis were male sex (odds ratio, 6.42 [95% confidence interval, 1.25-32.97], P=.026), posterior circulation involvement (3.57 [1.09-11.75], P=.036), and high total cholesterol levels (1.02 [1.01-1.03], P=.008). Male sex, hypercholesterolemia, and posterior circulation involvement are associated with higher likelihood of underlying IAD as the etiology for the intracranial arterial occlusion. In patients with these characteristics, underlying IAD may have to be considered and the endovascular treatment strategy may have to be modified.

Abstract T P11: What Clinical Factors Predict An Intracranial Arterial Stenosis Responsible For An Intracranial Larger Artery Occlusion Treated By Endovascular Therapy?

Objectives: In Asian countries where intracranial arterial stenosis (ICAS) is a common etiology regarding large artery intracranial occlusions in stroke. We sought to identify any clinical, laboratory and baseline imaging variables that may predict ICAS prior to endovascular treatment compared with angiographically-defined embolism (ADE). Methods: Patients were included if they had large cerebral artery occlusion in stroke on CT angiography and undertook transfemoral cerebral angiography, and if their onset to puncture time was within 8 hours. We defined ICAS and ADE by transfemoral cerebral angiography. ICAS was defined as fixed significant (&gt; 50%) focal stenosis in the occlusion site, which could be seen in the final angiography or during the procedure of endovascular treatment. ADE was defined by no focal stenosis was evident after some recanalization achieved. Patients were excluded if their cause of stroke was associated or combined with other etiologies. Results: Finally, a total of 157 patients were included for this study. Table shows comparisons of clinical laboratory and imaging characteristics between ICAS and ADE groups. Patients in ICAS group were younger and male-predominant than in those in ADE group. Dyslipidemia and smokers were more frequent in ICAS group. Total cholesterol level was higher in ICAS group than in ADE group. Compared to ADE an ICAS was much more common in the posterior circulation 11/30 versus only 12/127 in the anterior circulation (p&lt;0.001). Independent predictors of ICAS on multivariable analysis were male gender (odds ratio 6.34 [95% CI, 1.23-32.85], p=0.028), posterior circulation involvement (5.37 [1.62-17.82], p=0.006) and total cholesterol level (1.02 [1.004-1.033], p=0.012). Conclusion: The neurointerventionalist should prepare for the possibility of ICAS when performing endovascular treatment especially with posterior circulation occlusions in a Korean population.

Abstract W P121: Patterns Of Vessel Involvement In Patients With Intracranial Atherosclerosis Across Ages

Introduction: Intracranial atherosclerosis has been well studied in the aging population, much less is known about atherosclerotic stenosis in the young. Clinicians seek to control traditional vascular risk factors in this population, but differences in patterns of stenosis may call for varied treatment approaches. This study sought to compare age to the distribution of vessel involvement in patients with moderate-severe intracranial stenosis. Methods: This is a retrospective cohort study of patients with intracranial stenosis seen in the stroke clinic of a tertiary center from 2008-2013. Inclusion criteria were moderate-severe intracranial stenosis clinically felt to be due to atherosclerosis with ≥3 traditional vascular risk factors. Patients with other mechanisms of intracranial stenosis were excluded. Stenosis location and severity were based on cerebral angiography, CTA, or MRA. Patients were divided into young (&lt; 50 yr), middle-age (51-64 yr), or older (≥ 65 yr). All 69 patients ≤50 yr were included; a random sample of 69 patients &gt; 50 were selected for this analysis. Results: There were similar rates of vascular risk factors except HTN, which was less common in the young group (81.2% young, 100% middle, 96.8% older, p=0.0006). The location of stenoses varied by age category. Older patients had more posterior circulation involvement compared to the younger groups (p = 0.046), with more frequent involvement of vertebral and basilar arteries (p = 0.012) (Table). The occurrence of stenosis in the distal ICA and MCA vessels were similar among age groups. The frequency of ACA stenosis was highest in the young category (p = 0.026). Conclusion: There are differences in anatomic locations of presumed intracranial atherosclerosis across age groups with older patients (&gt; 65 yrs) having a higher rate of posterior circulation disease. This suggests potential differences in pathophysiological mechanisms. These findings warrant further investigation.

Posterior Cerebral Artery Insufficiency in Pediatric Moyamoya Disease.

The majority of clinical studies on moyamoya disease (MMD) have focused on anterior circulation. The disease involvement of posterior circulation in MMD, mainly in the posterior cerebral artery (PCA), has been mentioned since the early 1980s, and it has been repeatedly emphasized as one of the most important factors related to poor prognosis in MMD. However, its clinical features and outcome have only been elucidated during the last few years. In this review, the angiographic definition of PCA stenosis is summarized. The clinical features are elucidated as being either early-onset or delayed-onset, according to the time of PCA stenosis diagnosis in reference to the anterior circulation revascularization surgeries. The surgical strategy and hypothesis on the mechanism of PCA stenosis is also briefly mentioned. It appears that some MMD patients may show PCA stenosis during the early or late course of the disease and that the presenting symptoms may vary. Because the hemodynamic compromise caused by PCA stenosis may respond well to surgical treatment, clinicians should be aware of the condition, especially during follow-up of MMD patients.

Long-term outcomes in adult patients with ischemic-type moyamoya disease involving posterior circulation.

The object of this study was to compare the long-term outcomes in adult patients with moyamoya disease (MMD) with posterior circulation involvement (PCi) treated through surgical revascularization with those in adult patients without PCi. The records of 32 consecutive adult patients with ischemic-type MMD who were treated with revascularization were reviewed. Twelve of these patients (38 %) had PCi at initial onset. Clinical characteristics of the patients with PCi were compared to those without PCi. Neurological outcomes were assessed using the modified Rankin Scale (mRS) in the preoperative and postoperative follow-up periods. A five-year Kaplan-Meier stroke risk was calculated. The frequency of presenting with infarction was significantly higher among patients with PCi than among those without PCi (p = 0.006). mRS scores in the preoperative period were significantly higher in patients with PCi than in patients without PCi (p = 0.0004). There were no significant differences in mRS scores between the preoperative and postoperative follow-up period in patients with PCi (p = 0.3), nor were there any between the preoperative and postoperative follow-up periods in patients without PCi (p = 0.2). The five-year Kaplan-Meier risk of surgical morbidity and ipsilateral stroke was 14.3 % in surgically treated hemispheres with PCi versus 14.9 % in surgically treated hemispheres without PCi (p = 0.96). PCi at initial onset was significantly correlated with poor outcome. Revascularization for the middle cerebral artery territory in patients with PCi was effective at preventing recurrent ischemic stroke.

Reply to “Mechanisms of postoperative progression of steno-occlusive lesions in the posterior cerebral artery in moyamoya disease”

We thank Dr. Mugikura and his colleague for their comments on our paper “Posterior cerebral artery involvement in moyamoya disease: initial infarction and angle between PCA and basilar artery.” They have listed in detail three possible mechanisms that may bring about the progression of posterior cerebral artery (PCA) lesions in moyamoya disease (MMD): “primary progression” steno-occlusion of PCA, involution of PCA due to development of sufficient collaterals from the revascularization of anterior circulation, or occlusion of PCA due to presence of major infarctions. The latter two commonly hypothesize that the steno-occlusion of PCA is a secondary phenomenon of decrease in vascular demand from the PCA due to the reasons mentioned. We totally agree with their idea that the delayed progression of PCA is a primary phenomenon, related to the nature of the disease. As we mentioned in our paper, although the presence of preoperative infarction was strongly associated with progression of the PCA stenosis, this should not be interpreted as a causal relationship but as the concurrence of the two most influential factors affecting the prognosis of MMD. As our clinical experience with follow-up of MMD patients accumulate, we feel that many patients with PCA progression are “symptomatic” which means that the progression is not just the result of decreased demand of collaterals from the PCA but a real progression of ischemia of the PCA area. We agree that the second and the third mechanisms may accelerate the stenosis of PCAs. However, our indication for additional revascularization surgery of the PCA area requires presence and dominance of the first mechanism proposed in this commentary. Our paper focused on the clinical aspects, especially the preoperative factors related to delayed progression of PCA stenosis in MMD. The commentary by Dr. Mugikura and his colleague has greatly enriched the academic discussion on the topic of posterior circulation involvement in MMD.

Moving Vessel Wall Research Beyond the Plaque

The overlap between atherosclerotic disease of the cerebrovascular, cardiovascular, and peripheral vasculature has long been recognized. Carotid atherosclerosis increases the odds of coronary events1 and of finding atherosclerotic changes in coronary, cerebral, aortic, and iliac arteries.2 Similarly, peripheral vascular disease is a risk factor for both stroke and myocardial infarction and is associated with extracranial carotid and intracranial atherosclerosis.3,4 Data from the Reduction of Atherothrombosis for Continued Health (REACH) registry show that atherosclerosis in 1 vascular bed increases the risk of adverse outcomes in each of the other locations, and that multiple disease locations at baseline increase the risk of subsequent cardiovascular and cerebrovascular events.5 Given shared underlying risk factors and pathophysiology, it is not surprising that those who present with atherosclerotic disease in 1 vascular bed are at increased risk for disease in others.6 See accompanying article on page 2240 It is fair to say that although considerable attention has been given to atherosclerotic disease affecting peripheral, cardiac, and carotid arteries, important gaps remain in our knowledge. For example, the intracranial circulation has received comparatively …

Assessment of the difference in posterior circulation involvement between pediatric and adult patients with moyamoya disease

There is no description of the change in the posterior cerebral artery (PCA) in the diagnostic criteria of moyamoya disease (MMD). However, PCAs are often involved in the clinical setting, and an understanding of the significance of PCA lesions is therefore of great importance when evaluating the disease progression and predicting prognosis. The aim of this study was to assess the difference in posterior circulation involvement in pediatric and adult patients with MMD. The records of 120 consecutive patients with MMD were reviewed. The clinical manifestations at diagnosis were evaluated on the basis of symptoms and CT and MRI findings. The degree of steno-occlusive internal carotid artery (ICA) lesions and the existence of steno-occlusive PCA lesions were evaluated by observing a total of 240 ICAs and PCAs on angiography. Angiographic correlation between anterior and posterior circulation was assessed in pediatric and adult patients with MMD. Seventeen (26%) of 66 pediatric patients and 18 (33%) of 54 adult patients exhibited steno-occlusive PCA lesions. There was no significant difference in the prevalence of PCA lesions between pediatric and adult patients with MMD (p = 0.36). The prevalence of infarction in pediatric and adult patients with PCA involvement was significantly higher than that in pediatric and adult patients without PCA involvement (p = 0.0003 and p = 0.003, respectively). There was no significant difference in the distribution of infarction areas between pediatric and adult patients with PCA involvement (p = 0.62). On the basis of the staging system used, steno-occlusive lesions in ICAs ipsilateral to PCAs with lesions were in significantly advanced stages compared with lesions in ICAs ipsilateral to PCAs without lesions in both pediatric and adult cases (p < 0.0001 and p = 0.0008, respectively). Pediatric patients had less advanced steno-occlusive lesions in ICAs ipsilateral to PCAs with lesions compared with adults (p < 0.05). The clinical significance of posterior circulation involvement in MMD was similar between pediatric and adult patients. The only significant difference was that less advanced ICA lesions could complicate posterior circulation involvement in pediatric patients.

Intracranial Aneurysms in Children with Sickle-Cell Anemia

AbstractAbstract 4756 Background:Intracranial aneurysms in sickle-cell anemia (SCA) have been reported in about 50 adult patients, mostly presenting with subarachnoid hemorrhage (SAH). Aneurysms in those patients tend to be multiple (50%), to involve the posterior circulation more frequently than in the general population (33% vs 14%) and to be diagnosed at a younger age. In pediatric SCA patients, SAH has scarcely been reported, without evident link with stenotic cerebral vasculopathy. An associated intracranial aneurysm has only been demonstrated once in a teenager. Case reports:We report the cases of 2 children with sickle-cell anemia (HbSS) with intracranial aneurysms. The first patient was a 5-year old girl with abnormal transcranial Doppler (TCD) screening for cerebral vasculopathy: left middle cerebral artery time-averaged mean velocity (MCA TAMV) 208cm/sec, right MCA TAMV 196cm/sec. She had normal neurological assessment. On her brain MRA, no stenotic lesion was found within the Circle of Willis and the Internal Carotid arteries. A 6mm distal left posterior cerebral artery unruptured saccular aneurysm was observed. The brain MRI revealed a left thalamic lacunar infarction likely due to asymptomatic embolic infarction from the aneurysm. Longitudinal MR imaging showed spontaneous but incomplete thrombotic aneurysm occlusion. The second patient, an 11 year-old boy with slight cognitive delay and normal annual TCD procedures, presented with a non-traumatic SAH. Brain MRI showed several small silent cerebral infarctions in the white matter watershed territories. Brain MRA revealed multiple aneurysms without any stenotic lesion. A ruptured aneurysm was located on the basilar artery termination. Four unruptured aneurysms were found: 3 on the posterior cerebral arteries (1 right, 2 left) and 1 on the ophthalmic artery ostium. Endovascular coil embolization resulted in angiographic occlusion of the 2 accessible aneurysms. Clinical outcome was excellent. Discussion:Hemorrhagic strokes are more frequent than ischemic strokes in young adult SCA patients. Two main mechanisms are described: intracerebral or intraventricular hemorrhage due to major occlusive vasculopathy (moyamoya syndrome) or subarachnoid hemorrhage due to aneurysm rupture or leak. Our pediatric patients have no evidence for moyamoya syndrome. Their intracranial aneurysms bear similar characteristics with adult SCA patients': possibility of multiple aneurysms and posterior circulation involvement. They are observed at a very young age and are associated with mild cerebral vasculopathy: abnormal TCD without MRA stenosis in one case, silent cerebral infarcts without MRA stenosis in the other case. These findings plead for a possible concurrent development of vascular lesions leading either to ischemic or hemorrhagic stroke. This hypothesis is supported by similar histopathological findings in both aneurysms and cerebrovascular occlusive lesions in SCA: intimal hyperplasia, smooth-muscle layer hyalinization and elastic lamina fragmentation. This challenges the supposedly sequential pathophysiology of strokes in SCA, based on the high prevalence of infarctive strokes in children and hemorrhagic strokes in young adults. Conclusion:This report of pediatric intracranial aneurysms, associated with mild cerebral vasculopathy in both patients, supports the hypothesis of a common pathophysiological mechanism and the possible concurrent development of stenotic lesions and dilatations. This is also the first report of successful coil embolization in a pediatric SCA patient. Disclosures:No relevant conflicts of interest to declare.

Focal time-to-peak changes on perfusion MRI in children with Moyamoya disease: correlation with conventional angiography

Moyamoya disease is a chronic progressive steno-occlusion of the distal internal carotid arteries with unknown etiology. As the classical presentation of childhood Moyamoya disease is ischemic stroke, cerebral hemodynamic evaluation is important for patient selection for surgery to prevent recurrent ischemic attacks. Perfusion MR imaging has been applied to evaluate cerebral hemodynamics. To correlate the 'basal time-to-peak preservation sign', 'auto-synangiosis sign', and 'posterior involvement sign' on time-to-peak map of perfusion MRI with catheter angiography. Thirty-four children (6.91 ± 3.08 years) with Moyamoya disease who underwent both perfusion-weighted MRI and catheter angiography were enrolled in this study. Given catheter angiography as a reference standard, basal time-to-peak preservation sign, auto-synangiosis sign, and posterior involvement sign were evaluated on time-to-peak maps. The basal time-to-peak preservation sign was accurate for the diagnosis of childhood Moyamoya disease; both sensitivity and specificity were 100%. The auto-synangiosis sign showed lower sensitivity (65%), however, with an acceptable specificity (98%). The posterior involvement sign showed lower sensitivity (61%) but had an acceptable specificity (96%). The basal time-to-peak preservation sign may be a universal finding in childhood Moyamoya disease. The auto-synangiosis and posterior involvement sign may be useful in determining transdural collateral status and posterior circulation involvement in childhood Moyamoya disease.

Posterior Circulation Stroke after C1–C2 Intraarticular Facet Steroid Injection: Evidence for Diffuse Microvascular Injury

Posterior Circulation Stroke after C1–C2 Intraarticular Facet Steroid Injection: Evidence for Diffuse Microvascular Injury

Clinical Analysis on Alteration of Thyroid Hormones in the Serum of Patients with Acute Ischemic Stroke

Low T3 has been associated with increased short-term mortality in intensive care unit and long-term mortality in cardiovascular disease. The objective of this retrospective study is to investigate associations of thyroid hormone status with clinical severity and outcome in acute ischemic stroke, and whether there is association between the pituitary axis abnormality and the anterior/posterior circulation involvement. Patients with no history of thyroid abnormality who presented first ever stroke were studied. Total T3, T4, TSH levels, basic and clinical characteristics were collected and categorized. Neurological impairment was assessed using NIHSS and modified Rankin Scale. Twenty-nine patients (61%) had T3 ≤ 75 ng/dL. Low T3 group had significant higher NIHSS compared to normal T3 group. There was a significant negative correlation between T3 levels and NIHSS scores on admission. A significantly smaller percentage of patients with low T3 showed favorable neurological function improvement by both NIHSS and mRS measures compared to those with normal T3. There was no significant difference for anterior or posterior circulation involvement between low T3 and normal T3 groups. It is suggested that low T3 is associated with worse neurological outcome. The severity of low T3 may be a predictor of functional improvement in acute ischemic stroke.

Vertebral Artery Dissection in a Patient With Wildervanck Syndrome

Vertebral artery dissection as a cause of stroke is rarely reported in children. The association between vertebral artery dissection and Klippel-Feil syndrome is also very rare. We report on a case of vertebral artery dissection with posterior circulation involvement in a child with Klippel-Feil syndrome after a hard physical-training lesson. She was also diagnosed with Wildervanck syndrome, with additional clinical findings. Vertebral artery dissection should be considered in patients with Klippel-Feil syndrome who present with acute-onset neurologic signs. Movements such as hyperextension with rotation of the neck should be avoided in these cases.

Neurological complications of coronary angiographic procedures

Neurological complications of coronary angiographic procedures are uncommon, varied and can include central nervous toxicity caused by contrast agents (contrast reactions), as well as ischemic and hemorrhagic stroke. These complications are rare; however, more recent data derived from neuroimaging studies suggest that there is a higher incidence of ‘silent’ ischemic events. The impact of these subclinical events is still uncertain, but a few studies suggest that long term they may lead to cognitive decline, which is usually subtle. The clinical presentation of both contrast reactions and strokes can, at times, be very similar as there is a higher than expected incidence of posterior circulation involvement with both. While the treatment of contrast reactions is usually supportive, treatment of ischemic stroke in patients undergoing catheterization procedures appears, based on limited case report series, to lead to favorable outcomes with immediate neuroangiographic intervention, including local administration of recombinant-type tissue plasminogen activator.

Moyamoya Syndrome Associated With Down Syndrome: Outcome After Surgical Revascularization

This study was undertaken to describe the clinical, radiologic, and angiographic features of moyamoya syndrome in a surgical series of children and adults with Down syndrome. We wished to define the features of moyamoya syndrome associated with Down syndrome and to determine the results of surgical revascularization among these patients at early and late follow-up times. We reviewed the clinical, radiologic, and angiographic records of all patients with moyamoya syndrome associated with Down syndrome, as a subset of a previously reported, consecutive series of patients who underwent cerebral revascularization surgery with a standardized surgical procedure, pial synangiosis, between January 1, 1985, and June 30, 2004. Of 181 patients with moyamoya syndrome from the initial series who were treated surgically during the study period, 16 patients had Down syndrome (10 female patients and 6 male patients). The average age at onset was 9.3 years (range: 1-29 years); the average age at the time of surgery was 9.8 years (range: 2-29 years). Although the presenting symptoms were transient ischemic attacks for 10 patients and strokes for 6 patients, computed tomographic and/or MRI scans demonstrated bilateral infarctions for 9 patients and unilateral infarctions for 6, with only 1 patient having no imaging evidence of a previous stroke. No cases presented with intracerebral hemorrhage. Preoperative angiography showed the presence of bilateral moyamoya syndrome changes for all patients, including posterior circulation involvement for 8 patients. Surgical treatment included pial synangiosis for all patients, although 1 patient underwent a superficial temporal artery-middle cerebral artery bypass in the contralateral hemisphere. Surgical complications included symptomatic subdural hematomas requiring evacuation, at 48 days and 54 days postoperatively (2 cases), seizures (2 cases), and strokes within 30 days after surgery, at 1 day and 7 days postoperatively (2 cases). Late clinical and radiologic follow-up data (average: 67.6 months; range: 6-146 months) demonstrated no worsening in neurologic status for any patient except for 1 patient who developed a seizure disorder with associated chronic hypocalcemia; she was totally dependent at the 10-year follow-up evaluation, despite no evidence of new infarction since her surgery. There was no clinical or radiologic evidence of new infarction for any patient in late follow-up evaluations. Postoperative angiography, conducted 1 year after surgery for 11 patients, revealed radiologic evidence of good to excellent cerebral revascularization in 85% of the surgically treated hemispheres. Patients were maintained on lifetime aspirin therapy. The clinical, radiologic, and angiographic features of moyamoya syndrome associated with Down syndrome seem comparable to those of primary moyamoya disease. Cerebral revascularization surgery with the pial synangiosis technique seems to confer long-lasting protection against additional strokes in this patient population. The presence of moyamoya syndrome should be considered in the evaluation of patients with Down syndrome who present with transient ischemic attack-like symptoms.

Progression in acute ischemic stroke: Frequency, risk factors and prognosis

Background and purpose: The aim of this study was to investigate the frequency, possible predictive factors and the prognosis of deteriorating ischemic stroke. Methods: A total of 266 stroke patients who presented within 24 h of onset were enrolled. Clinical deterioration was defined as a decrease of ⩾1 points in the Canadian Neurological Scale (CNS). Rankin Score (RS) was performed at discharge and at six months. Results: Of the 266 patients studied, 26 (9.8%) worsened. Involvement of posterior circulation (odds ratio (OR) 3.16) and noncardioembolic infarction (OR 4.5) were found to be independently associated with neurological worsening. Death occurred in 19.2% of progressive (P) and in 4.16% of nonprogressive (NP) groups. Functional outcome was worse in the P than in NP patients at discharge and at sixth months. Conclusions: Involvement of posterior circulation and noncardioembolic subtypes of infarct independently affect neurological progression in acute ischemic stroke. Clinical deterioration significantly worsens the prognosis.

Ischemic stroke and active migraine.

To determine the characteristics of acute ischemic stroke (IS) in patients with active migraine in a prospective stroke registry. The authors studied the characteristics of patients admitted to a population-based primary-care center with IS and active migraine. The diagnosis of previous migraine was made based on replies to International Headache Society-based questions. Patients with migraine were divided into two age groups, one below 45 years of age and one 45 years or older, and compared by univariate and multivariate analysis with age-matched control subjects with IS, but without migraine. Of the 3,502 patients with acute IS, 130 (3.7%) had active migraine; 66 of these were younger than 45 years and 64 were 45 years or older (15.8% and 2.1% of the total for the corresponding age group). The proportion of women was significantly higher in both groups of patients with migraine (74% and 63% in the younger and older groups) than in control subjects. In young migraineurs, the posterior circulation involvement and the presence of patent foramen ovale were characteristic. In the younger migraine group, nine patients developed IS during a typical attack of migraine with aura, and 15 during migraine attack without aura in the absence of any other determined cause. In the older group, surprisingly, absence of vascular risk factors (previous hypertension, ischemic heart disease, and cigarette smoking) was characteristic. Migraine is frequent in young patients with IS and infrequent in older patients with IS. Patients with IS and migraine are mainly women with stroke features that are age dependent.

Basilar artery stenosis: Clinical and neuroradiographic features

Although basilar artery stenosis (BAS) is an important cause of posterior circulation stroke, few reports detail the clinical and neuroradiological features of patients with BAS. A retrospective review of symptomatic BAS patients who were evaluated by our Stroke Center. Twenty-eight patients were followed-up for a median of 16 months. Transient ischemic attacks (TIAs) specific for posterior circulation involvement were common (12/19 patients with TIA), were often multiple, and frequently preceded a posterior circulation stroke. The proximal (13/28) and mid (10/28) basilar arteries were the most common sites of stenosis. Brain infarction most often affected the pons, but also frequently involved the cerebellum and thalamus. Concomitant vertebral artery disease was prevalent (12/18 patients who underwent conventional cerebral angiography). Stroke mechanisms included artery to artery embolus, basilar branch disease, and hypoperfusion. The same-territory recurrent stroke rate was 8.2% per year. Most patients in the series were treated with warfarin. No patients suffered a recurrent stroke while on a therapeutic dose of warfarin (international normalized ratio [INR], 2.0 to 3.0). Angioplasty was performed in 6 patients. The same-territory stroke recurrence rate was 8.2% per year. Warfarin (INR, 2.0 to 3.0) appeared to be effective in preventing recurrent strokes. Angioplasty of the basilar artery was technically feasible. Symptomatic BAS typically affected the proximal and mid-basilar artery and most often caused infarction in the pons. The mechanisms for stroke were heterogeneous. TIAs frequently preceded a posterior circulation stroke.

Moyamoya disease in adults: characteristics of clinical presentation and outcome after encephalo-duro-arterio-synangiosis

To determine the clinical characteristics and the effectiveness of encephalo-duro-arterio-synangiosis (EDAS) in adulthood-onset Moyamoya disease (MMD), the authors retrospectively reviewed 26 patients suffering from MMD who were admitted to Seoul National University Hospital between 1987 and 1995. When they showed major symptoms, all were more than 16 years-old. The most common presenting symptom was intracranial hemorrhage (ICrH), found in 12 patients or 46% of the total; the second was infarction and transient ischemic attack, each found in seven or 27% of them. Only one patient was found to have seizures, which were associated with a cerebral infarction. The Suzuki angiographic stage 3 and less than stage 3 accounted for 73% of all 52 hemispheres. A total of 15 patients underwent single photon emission computed tomography (SPECT) preoperatively. When the derangement of cerebral perfusion was estimated with four SPECT grades (SG), 70% of their hemispheres revealed normal (SG1) or localized decreased-perfusion (SG2). The other 30% had extensive decreased-perfusion or localized perfusion defects (SG3). There was no case who had extensive perfusion defects (SG4). A total of 17 patients underwent EDAS operations (EDAS group) and nine did not undergo any operation (no-op group). The EDAS group had significantly better clinical outcomes than the no-op group after a 12-month median follow-up period (P<0.05). The angiographic and SPECT follow-up studies comprised six and seven cases, respectively. There was also satisfactory angiographic revascularization in all follow-up cases and improvement in cerebral perfusion at SPECT follow-up in six of seven cases. It is concluded that the involvement of posterior circulation of MMD is not frequent and cerebral perfusion is preserved in adulthood-onset MMD patients. These findings may explain the reason why hemorrhages are frequent and the late onset of symptoms in adulthood-onset MMD. Surgical treatment with EDAS seems to be effective in adulthood-onset MMD in terms of clinical improvement.