Posterior Circulation Transient Ischemic Attacks Research Articles

Prevalence of intracerebral thrombus detected by optical coherence tomography in patients with posterior circulation stroke or transient ischemic attack

BackgroundThe incidence of thrombosis in patients with intracranial atherosclerotic stenosis (ICAS) remains unclear. Optical coherence tomography (OCT) has the potential to explore the vessel wall structure of posterior-circulation ICAS because...

Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness

Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome, or EVS) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack (pc-TIA). Because these patients are by definition, asymptomatic without new neurological findings on exam, the diagnosis, largely based on history and epidemiological context, can be challenging. We review literature that addresses the frequency of pc-TIA in this group of patients, compared to other potential causes of the EVS. We present ways of distinguishing pc-TIA from vestibular migraine, the most common cause of the EVS. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.

Association between vertebrobasilar artery geometry and vertebrobasilar stenosis, recurrence, and death in posterior circulation stroke and transient ischemic attack

BackgroundIntracranial atherosclerosis is one of the primary causes of posterior circulation stroke and transient ischemic attack (TIA), particularly in people of South and East Asian heritage. Focal vessel geometry may play a role in atherosclerosis progression. Thus, we investigated the relevance of vertebrobasilar artery (VBA) geometry and vertebrobasilar atherosclerotic stenosis, recurrence, and death in posterior circulation stroke and TIA. MethodsFour hundred and twenty patients with posterior circulation ischemic stroke or TIA were included. The VBA geometric features, comprising the geometric configurations (Tuning fork, Walking, Lambda, and No confluence), vascular bends (multi-bending and oligo-bending), and VBA stenosis degrees, were defined based on computed tomography angiography (CTA) images. Recurrence of stroke or TIA and death were assessed through a 1-year follow-up. Additionally, the relationship between VBA geometric features, VBA stenosis, and prognosis were analyzed. ResultsWalking type and vascular multi-bending showed significant associations with more severe VBA stenosis and distribution, and these were also more frequently observed in patients with large-artery atherosclerosis (LAA) stroke (all P < 0.05). Sixty-four patients exhibited recurrent stroke or TIA, and 31 died during the 1-year follow-up. In the binary logistic regression analysis, Walking type (P = 0.018), Lambda type (P = 0.021), and multi-bending type (P = 0.004) were found to be independently associated with stroke recurrence, while No confluence type was independently associated with death (P = 0.010). ConclusionsThe geometric characteristics of the VBA are associated with vertebrobasilar stenosis, LAA stroke, 1-year recurrence, and death in posterior circulation stroke and TIA. VBA geometry may be used to stratify the risk of stroke and TIA in the posterior circulation.

Clinical Progress and Prognosis in TIA: Experiences of a Specialised Neurology Hospital

Objective: The current development of acute stroke units led to an increase in morbidity of stroke patients while causing a decrease in overall mortality. Therefore, the cost of stroke care and treatment took a serious toll on national economies worldwide. Primary prevention of stroke should remain the main objective of primary healthcare. Following a transient ischemic attack (TIA), the patients have a 10-20% risk of developing an ischemic stroke. Our main objective in the present work was to summarize risk factors, imaging modalities, etiologic factors, and treatment modalities in TIA patients and to determine the rate of recurrence of TIA and ischemic stroke incidence in 1 year follow up in an academic medical center specialized in neurology. Method: 119 patients with TIA who received inpatient management in a 3-year period were included in this study. Patients were grouped by age, gender, distribution and duration of symptoms; recurrence, risk factors, and history of antiplatelet/anticoagulant use. A routine stroke protocol was followed for all patients. The patients were stratified by OCSP and TOAST criteria. The patients were re-evaluated at 3rd, 6th, and 12th months after discharge, and new stroke/TIA occurrence rate, risk factors and the presence of ischemic lesions on neuroimaging were recorded. Results: Of the patients who were included in this study, 52.9% was male, 42.1% was female. 87 of the patients (73.1%) had anterior circulation and 32 of the patients (26.9%) had posterior circulation pathologies. Recurrence of symptoms was observed in 60 patients (50.4%) after the first event. Diabetes, hyperlipidemia and hypertension were discovered to be the closest risk factors to be proven statistically significant. Posterior circulation TIA, and cardioembolic TIA ratios were more frequent when compared to the literature. During the one year follow up 8.4% of the patients reported experiencing new ischemic stroke or TIA, and only 2 patients died. Conclusion: Tight risk factor control and adherence to treatment protocols selected based on etiology are critical to decreasing ischemic stroke incidence following TIA.

Ischemia Modified Albumin and miR-126 Play Important Role in Diagnosis of Posterior Circulation Transient Ischemic Attack and Prediction of Secondary Cerebral Infarction

Transient ischemic attack (TIA) is a super warning for cerebral infarction stroke, thus probe of sensitive biomarker for TIA diagnosis and prognosis can contribute to make an optimal intervention plan. This study was conducted to explore the value of ischemic modified albumin (IMA) and microRNA-12miR-126 on the diagnosis of posterior circulation TIA and the prediction of secondary cerebral infarction. This study was conducted as a longitudinal prospective research. The levels of serum IMA and miR-126 at 3h, 6h and 12h after TIA onset were analyzed in 106 patients, then the predictive value of IMA and miR-126 for secondary cerebral infarction were tested. A significant increase of serum IMA and a decrease of miR-126 were observed after TIA onset (P = 0.000),simultaneously a significant negative correlation was found between serum IMA for 3 h and miR-126 for 12 hr=-0.401, P = 0.000. Both IMA and miR-126 were significant associated with the secondary cerebral infarction. Early detection of IMA and miR-126 is of great value in diagnosing posterior circulation TIA and predicting the secondary cerebral infarction.

Bilateral vertebral artery dissection complicated by posterior circulation stroke in a young man

Introduction:Vertebral artery dissection (VAD) is a common cause of stroke in young and mid-aged adults without predisposing risk factors for vascular disease. It can be induced by a particular head or neck posture; its early signs often include headache and neck pain. Improved imaging techniques can be used to detect VAD, whose current treatment options are limited.Patient concerns:The patient presented with neck and shoulder pain for a week after sleeping against the wall with cervical proneness for 1 night. He had sudden headache, slurred speech, and left side weakness for 1.5 hours on admission.Diagnosis:The patient had VAD complicated by posterior circulation stroke.Interventions:Acute stroke was treated with intravenous thrombolytic therapy. Then, the patient was administered follow-up anticoagulants.Outcomes:The patient's condition improved after thrombolytic therapy. He recovered well, with no recurrence during a 4-year follow-up.Conclusion:VAD should be taken into consideration in differential diagnosis of posterior circulation stroke or transient ischemic attack in young patients. Intravenous thrombolytic therapy may be safe and effective for stroke-complicated cases. This case report demonstrates that expanded diagnostic protocol for acute ischemic stroke assures rapid and correct diagnosis.

Assessment of Intracranial Atherosclerotic Plaques Using 3D Black-Blood MRI: Comparison With 3D Time-of-Flight MRA and DSA.

Noninvasive assessment of intracranial stenosis is important to manage ischemic stroke patients. However, few previous studies have compared 3D black-blood MRI with 3D time-of-flight (TOF), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) for intracranial artery plaque assessment. To compare 3D black-blood MRI and 3D TOF-MRA, using DSA as the reference standard for intracranial stenosis and atherosclerotic plaque assessment in patients with posterior circulation stroke or transient ischemic attacks (TIAs). Prospective, cohort study. One hundred and one patients with posterior circulation stroke and/or TIA (age 63 ± 10 years, 84 male) who underwent DSA and MRI within 4 weeks of each other. 3D fast-spin-echo MRI for intracranial vessel wall imaging (IVWI) and 3D TOF at 3T. Two radiologists independently measured the degree of stenosis on 3D IVWI and TOF, using DSA as a reference. Plaque enhancement was recorded when the plaque was stenosis-free on DSA. Shapiro-Wilk's test, Student's t-test, Mann-Whitney U-test, Spearman correlation, Bland-Altman analysis, and interclass correlation coefficient (ICC). A total of 238 intracranial plaques (203 posterior, 35 anterior) were included. 3D IVWI showed better agreement with DSA in measuring stenosis than TOF (ICC = 0.89 vs. 0.64). 3D IVWI had higher sensitivity and specificity for detecting stenosis >50% and stenosis >75% than TOF, using DSA as the standard. TOF significantly overestimated the degree of stenosis compared to DSA (65 ± 19% vs. 51 ± 15%, P < 0.001). DSA did not observe 62 nonstenotic plaques (26.1%) that were shown only on 3D IVWI, in which 36 plaques (58.1%) showed contrast enhancement. The interreader agreement for measuring stenosis were excellent, with ICCs >0.90 for all three modalities. 3D black-blood MRI is accurate and reproducible for quantifying intracranial artery stenosis compared with DSA, and performs better than 3D TOF. As compared to DSA, it detects more nonstenotic plaques. Level of Evidence 1 Technical Efficacy Stage 2 J. MAGN. RESON. IMAGING 2021;53:469-478.

Abstract TP84: Prognostic Factor of Intracranial Vertebral Artery Dissection: High Resolution Vessel Wall Magnetic Resonance Imaging Study

Background: Vertebral artery dissection (VAD) is well recognized cause of stroke in young and middle aged individuals. But, prognostic factor of posterior circulation ischemic stroke or transient ischemic attack (TIA) caused by intracranial VAD has been rarely discussed. Our aim was to evaluate the predictors of poor outcomes in posterior circulation ischemic stroke caused by intracranial VAD. Methods: We retrospectively reviewed patients with posterior circulation ischemic stroke or TIA caused by intracranial VAD using high-resolution vessel wall MRI who were recruited from Samsung Medical Center Stroke Registry (between January 1, 2011 and April 30, 2019). Poor outcomes were defined as a 3-months modified Rankin scale (mRS) score ≥ 2. Results: We registered 96 patients (74 males; mean age, 58.9±14.2 years) with acute posterior circulation ischemic stroke or TIA caused by intracranial VAD. Trauma history associated with VAD was presented in 23 (24%) of patients. Headache and neck pain around neurological symptom onset were presented in 41 (42.7%) and 19 (19.8%) of patients, respectively. Dissecting aneurysm, bilateral vertebral artery involvement, basilar artery involvement and wall hematoma with dissection were presented in 26 (27.1%), 26 (27.1%), 12 (12.5%) and 66 (68.8%) of patients, respectively. Of the 96 VADs, 26 (27.1%) presented with focal stenosis, 21 (21.9%) with multifocal stenosis, and 57 (59.4%) with occlusion. Lateral medulla involvement and multiple territory involvement were presented in 35 (36.5%) and 31 (32.3%) of patients. Recurrence rate of ischemic stroke or TIA within 90 days of symptom onset was 6.25%. Twenty-nine patients (30.2%) had poor outcomes at 3 months. Lateral medulla involvement was an independent predictor for poor outcome (odds ratio=3.293, 95% confidence interval=1.301-8.333, p=0.012). Conclusion: Posterior circulation ischemic stroke or TIA caused by intracranial VAD is associated with relatively benign clinical course. But the presence of lateral medulla involvement is independent predictor for poor outcome. Patients presenting lateral medullary infarction caused by intracranial VAD should be monitored closely.

Room tilt illusion: a chief complaint need to be alert in otology clinic

Objective:This study aims to investigated the clinical significance of room tilt illusion（RTI） in screening for central vertigo in otology clinic. Method:A retrospective study of 8 RTI cases out of 656 patients with dizziness and/or vertigo. The characteristics of the symptoms, signs, physical examination, and other examinations of RTI patients were analyzed. Result:①Patients with RTI complaints accounted for 1.2% of all patients with dizziness and/or vertigo in the same period. Of all 8 patients, 2 were with acute vestibular syndrome, 5 were with episodic vestibular syndrome, and one had no dizziness and/or vertigo attack. ②Two was diagnosed with acute cerebellar infarction, and 3 was diagnosed with posterior circulation transient ischemic attacks, 2 were diagnosed with definite vestibular migraine, and one was unable to identify the cause. ③All 8 patients had a sensation of environment tilting, which was episodic（single or repeated）, transient（seconds to minutes）, in the coronal plane, and with tilt angle 30-180°. ④Seven patients had dizziness and/or vertigo for minutes to hours after a transient RTI, and one patient had no other symptoms after RTI. ⑤All patients had no decrease in vHIT gain, 6 patients had abnormal oculomotor function, and one patient had mild horizontal semicircular canal paresis. Conclusion:Patients with RTI complaints mainly had central dizziness and vertigo diseases, and once are found in otology clinic, should be alert to the possibility of suffering from central diseases.

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

Headache in transient ischemic attacks

BackgroundHeadache is a common feature in acute cerebrovascular disease but no studies have evaluated the prevalence of specific headache types in patients with transient ischemic attacks (TIA). The purpose of the present study was to analyze all headaches within the last year and the last week before TIA and at the time of TIA.MethodsEligible patients with TIA (n = 120, mean age 56.1, females 55%) had focal brain or retinal ischemia with resolution of symptoms within 24 h without presence of new infarction on MRI with DWI (n = 112) or CT (n = 8). All patients were evaluated within one day of admission by a single neurologist. As a control group we used patients (n = 192, mean age 58.7, females 64%) admitted with diagnoses “lumbago”, “lumbar spine osteochondrosis” or “gastrointestinal ulcer”.ResultsOne-year prevalence of migraine without aura was significantly higher in TIA patients than in controls: 20.8% and 7.8% respectively (p = 0.002, OR 3.1, 95% CI 1.6–6.2). 22 patients (18.3%) had sentinel or warning headache within the last week before TIA. At the time of TIA a new type of headache was observed in 16 patients (13.3%). No controls had a new type of headache. 12 of these 16 patients had migraine-like headache, 8 patients had tension-type-like headache and one patient thunderclap headache. Posterior circulation TIA was associated with headaches within last week before TIA and at the time of TIA much more frequently than anterior circulation TIA.ConclusionsThe one year prevalence of migraine was significantly higher in TIA patients than in controls and so was the prevalence of headache within the last week before TIA and at the time of TIA. A previous headache that worsens and a new type of headache can be a warning of impending TIA.

Hemodynamics in stented vertebral artery ostial stenosis based on computational fluid dynamics simulations

Hemodynamic factors may affect the potential occurrence of in-stent restenosis (ISR) after intervention procedure of vertebral artery ostial stenosis (VAOS). The purpose of the present study is to investigate the influence of stent protrusion length in implantation strategy on the local hemodynamics of the VAOS. CTA images of a 58-year-old female patient with posterior circulation transient ischemic attack were used to perform a 3D reconstruction of the vertebral artery. Five models of the vertebral artery before and after the stent implantation were established. Model 1 was without stent implantation, Model 2–5 was with stent protruding into the subclavian artery for 0, 1, 2, 3 mm, respectively. Computational fluid dynamics simulations based on finite element analysis were employed to mimic the blood flow in arteries and to assess hemodynamic conditions, particularly the blood flow velocity and wall shear stress (WSS). The WSS and the blood flow velocity at the vertebral artery ostium were reduced by 85.33 and 35.36% respectively after stents implantation. The phenomenon of helical flow disappeared. Hemodynamics comparison showed that stent struts that protruded 1 mm into the subclavian artery induced the least decrease in blood speed and WSS. The results suggest that stent implantation can improve the hemodynamics of VAOS, while stent struts that had protruded 1 mm into the subclavian artery would result in less thrombogenesis and neointimal hyperplasia and most likely decrease the risk of ISR.

Rotational Vertebral Artery Compression Syndrome: Bow Hunter's Stroke

Rotational vertebral artery occlusion is a rare syndrome characterized by vertebrobasilar insufficiency secondary to position-dependent occlusion of the vertebral artery. Most cases reported in the literature have been attributed to osteophytic compression, either from the occipital condyle or within the transverse foramen. However, vertebral artery dissection secondary to motion in the setting of anomalous anatomy has not been reported.To the authors' knowledge, rotational vertebral artery occlusion and dissection secondary to anomalous entrance into the transverse foramen have never been reported. The authors describe the case of a 42-year-old male who presented with multiple posterior circulation transient ischemic attacks. Standard digital subtraction cerebral angiography demonstrated a non−flow-limiting right vertebral artery dissection, while dynamic digital subtraction cerebral angiography was remarkable for right vertebral artery stenosis that worsened with neck rotation. Computed tomography angiography of the neck revealed an anomalous course of the right vertebral artery, which entered the transverse foramen at C4 with preforaminal compression by the anterior tubercle of the C5 transverse process. The patient had no further symptomatic events after decompression of the vertebral artery by resecting the anterior C5 tubercle.In the setting of codominant vertebral circulation and unilateral bony compression, the authors propose that neck rotation led to vertebral artery trauma, causing dissection complicated by thromboembolism. This is a novel and unusual entity that is different from Bowhunter's syndrome.

Nonfocal Symptoms are More Frequent in Patients with Vertebral Artery than Carotid Artery Stenosis

Introduction: In patients with a transient ischemic attack (TIA) or ischemic stroke, the combination of focal and nonfocal symptoms has been associated with a higher risk of cardiovascular events. We hypothesized that nonfocal symptoms are more frequent in patients with symptomatic stenosis of a vertebral artery (VA) than of a carotid artery (CA). Therefore, we assessed the prevalence of nonfocal symptoms in patients with a recent TIA or nondisabling ischemic stroke and studied their relation with symptomatic CA or VA stenosis. Methods: We administered a standardized questionnaire on the occurrence of focal and nonfocal symptoms during the qualifying TIA or nondisabling ischemic stroke and in the preceding 6 months. We included 50 consecutive patients with a recently symptomatic CA stenosis ≥50%, 50 consecutive patients with a recently symptomatic VA stenosis ≥50%, 25 consecutive patients with an anterior circulation event without an ipsilateral CA stenosis ≥50%, and 25 consecutive patients with a posterior circulation event without a relevant VA stenosis ≥50%. Relative risks for the presence of nonfocal symptoms in relation to the presence of a symptomatic stenosis were calculated with univariate and multivariate Poisson regression. Adjustments were made for age, sex, stroke as the qualifying event, and cardiovascular risk factors. A subgroup analysis was performed for patients in whom the vascular territory of the event was confirmed on imaging. Results: During the qualifying ischemic event, focal symptoms were accompanied by nonfocal symptoms in 80 (53%) patients. Nonfocal symptoms occurred more frequently in patients with a VA stenosis (72%) than in patients with a CA stenosis [26%; adjusted relative risk (aRR), 2.9; 95% confidence interval (CI), 1.8-4.6]. A higher prevalence of nonfocal symptoms was found in patients with posterior circulation TIAs and strokes (73%) than in patients with anterior circulation TIAs and strokes (33%; aRR, 2.2; 95% CI, 1.6-3.1). During the preceding 6 months, 45% of patients with and 20% of patients without a symptomatic stenosis had had nonfocal symptoms (aRR, 2.4; 95% CI, 1.3-4.3). Subgroup analysis for the 89 (59%) patients with ischemia visible on imaging gave essentially the same results. Conclusions: More than half of the TIAs or nondisabling ischemic strokes were associated with nonfocal neurological symptoms. Nonfocal symptoms occurred more frequently in patients with a symptomatic VA stenosis than CA stenosis.

Stroke Risk After Posterior Circulation Stroke/Transient Ischemic Attack and its Relationship to Site of Vertebrobasilar Stenosis

Recent prospective studies have shown vertebrobasilar (VB) stenosis predicts stroke risk in posterior circulation stroke and transient ischemic attack. It is unclear whether this association is independent of other risk factors, and whether intracranial or extracranial stenosis confers different risks. A pooled individual patient analysis of data from 2 prospective studies was performed in 359 patients presenting with VB transient ischemic attack or stroke. Contrast-enhanced magnetic resonance angiography, or computed tomography angiogram, and clinical follow-up were available in 323 patients. Risk of stroke was calculated from any VB transient ischemic attack/stroke in the month before the presenting episode (first event) and from the presenting event. A systematic review of similar prospective studies was performed. Ninety-day risk of stroke from the first event was 24.6% in patients with VB stenosis versus 7.2% in those without (odds ratio, 4.2; 95% confidence interval, 2.1-8.6; P<0.0001). Risk was higher (33%) with intracranial (odds ratio, 6.5; 2.8-15.0; P<0.0001) than extracranial stenosis (16.2%; odds ratio, 2.5; 0.9-6.8; P=0.06). Risk from the presenting event was 9.6% in patients with stenosis versus 2.8% in those without (odds ratio, 3.7; 1.2-11.0; P=0.012), and again the risk was higher with intracranial stenosis. Cox regression showed the risk associated with VB stenosis was independent of other cardiovascular risk factors. The systematic review identified only 1 other report, which included only 6 patients. Symptomatic VB stenosis, particularly intracranial stenosis, is a strong independent predictor of stroke recurrence. The high early risk of stroke provides a strong rationale for randomized trials to determine whether stenting can reduce risk.

The Diagnosis of Vertebrobasilar Insufficiency Using Transcranial Doppler Ultrasound

Background. Vertebrobasilar insufficiency (VBI) is a hemodynamic posterior circulation transient ischemic attack (TIA) caused by intermittent vertebral artery occlusion that is induced by a head rotation or extension. VBI may result from large vessel atherosclerotic disease, dissection, cervical compressive lesions, and subclavian steal phenomenon. Diagnostic transcranial Doppler (TCD) of VBI disease and hemodynamic posterior circulation TCD monitoring in symptomatic positions might prove a useful tool in establishing the diagnosis. Patient and Material/Method. A 50-year-old Caucasian man presented with a one-year history of episodic positional vertigo and ataxic gait that were induced by a neck extension and resolved by an upright position or a neck flexion. Computed tomography angiogram (CTA) and TCD confirmed the presence of VBI where no blood flow was detected through posterior cerebral arteries in the symptomatic position (head extension position). Conclusion. TCD is a promising noninvasive technique that might have a role as a diagnostic test in VBI.

Dolichoectasia of the Intracranial Arteries

Dolichoectasia is a dilatation and elongation of the arteries, usually affecting intracranial basilar and vertebral arteries. It may cause posterior circulation stroke or transient ischemic attacks independent of atherosclerotic disease. Compression of cranial nerves or brainstem leads to hemifacial spasm, trigeminal neuralgia, or brainstem dysfunction (temporary or permanent). Intracranial bleeding is another possible manifestation. In general, the mortality and morbidity is higher in patients with dolichoectasia. Progression of arterial dilatation or elongation is an ominous sign for poor prognosis. Optimal treatment for vertebrobasilar dolichoectasia is uncertain. Adequate control of blood pressure may prevent ischemic or hemorrhagic stroke. In case of ischemic stroke, antiplatelet treatment is indicated for the prevention of recurrent stroke. However, the risk of hemorrhagic stroke should be considered in patients with severe forms of dolichoectasia. Close observation and follow-up neuroimaging is recommended to monitor the progression of the disease and appearance of new ischemic or hemorrhagic lesions. Surgical decompression may be reserved for the medically intractable patients with trigeminal neuralgia or hemifacial spasm.

Percutaneous transluminal angioplasty and stenting of the vertebral artery ostium with balloon-mounted bare coronary stents

Vertebral artery ostial stenosis (VAOS) is one of the most frequent causes of posterior circulation stroke. Percutaneous angioplasty and stenting (PTAS) is one of the treatment modalities. This is a longitudinal observational study from September 2006 to February 2009, conducted at hospitals affiliated with the Shiraz University of Medical Sciences, Shiraz, southern Iran. The patient cohort included patients with posterior circulation stroke or transient ischemic attack (TIA) and more than 70% VAOS, and patients with asymptomatic VAOS of more than 70% and aplasia or total occlusion of the contralateral VA or subclavian artery. All the patients underwent PTAS with balloon-mounted bare coronary stents. Technical success, procedural complications, composite outcomes of death, stroke or TIA in the vertebrobasilar territory during the first 30 days, stroke or TIA in the vertebrobasilar territory, and restenosis during follow-up, were assessed. During the study period, 81 patients (mean age 68 + 8.9 years, 63 (78%) males, 71 symptomatic and 18 asymptomatic) underwent the procedure. Technical success was achieved in 88 (99%) patients. Procedure-related complications, other than puncture site complications, were seen in two patients (2.2%). The composite outcome of death, stroke or TIA in the vertebrobasilar territory during the first 30 days was 1%. None of the patients had clinical recurrence or restenosis during the follow-up (mean follow-up 14 months). Percutaneous transluminal angioplasty and stenting of the proximal VA was feasible and safe. The risk of restenosis should be analyzed in long-term studies with angiographic follow-up.

Drug-eluting stent for the treatment of symptomatic vertebral origin stenosis

Objective To evaluate mid - long outcomes of drug - eluting stent (DES) for vertebral artery origin stenosis. Methods The demographics, indications for treatment, procedural technique, and clinical and radiographic follow - up were analyzed retrospectively in 47 consecutive patients treated with drug -eluting stents. Results 47 patients with 49 lesions were successfully treated with stent. No peri -procedural complications occurred. The mean degree of stenosis reduced from 72% to 9%. Symptoms were resolved in 11 cases, improved in 30 cases, unchanged in 6 cases. During follow - up for 2 - 48 months (mean 28. 3 months), tow cases had posterior circulation transient ischemic attack (TIA). Angiographic fowllow -up of 3 -34 months was obtained in 28 patients (59%) with a mean of 12. 2 months. Restenosis inside the stent (IRS) was observed in 2 patients and one present with drop attack. Stent fracture occurred in 4 patients, in which 2 cases with IRS. Conclusions VA origin stenosis can be treated safely and effectively with DES. Compared with the bare stent, DES can significantly reduces the rates of restenosis. Key words: Vertebral artery stenosis; Vertebrobasilar insufficiency; Posterior circulation ischemia; Angioplasty ; Stents

New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes.

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs before strokes, and 16% had only posterior circulation TIAs. Embolism was the commonest stroke mechanism accounting for 40% of cases (24% cardiac origin, 14% arterial origin, 2% had potential cardiac and arterial sources). In 32%, large artery occlusive lesions caused hemodynamic brain infarction. Stroke mechanisms in the posterior and anterior circulation are very similar. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes), while the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Infarcts that included the distal territory were twice as common as those that included the proximal or middle territories. Most distal territory infarcts were attributable to embolism. Thirty day mortality was low (3.6%). Embolic stroke mechanism, distal territory location, and basilar artery occlusive disease conveyed the worst prognosis.