Posterior Circulation Transient Ischemic Attacks Research Articles

Endarterectomy of the Intradural Vertebral Artery Via the Far Lateral Approach

Transient ischemic attacks (TIAs) of the posterior circulation are associated with a significant risk of subsequent infarction, particularly when caused by stenotic lesions in the intracranial portion of the vertebral artery (VA). Eight patients who had persistent posterior circulation TIAs despite receiving maximal medical therapy (including anticoagulation) and who had angiographic evidence of severe stenosis of the proximal intracranial VA with poor collateral flow were treated by endarterectomy of the intradural VA. Their ages ranged from 52 to 65 years. Five of these operations were performed via the far lateral approach. In all patients, the contralateral VA was hypoplastic or occluded, or ended in the posterior inferior cerebellar artery. Postoperative angiograms showed that the arteries of five of the patients were widely patent, one was improved but still stenotic, and two were occluded. The latter two patients subsequently underwent thrombectomy, after which the artery was patent in one patient and remained occluded in the other. After surgery, the TIAs of seven patients were relieved completely, and the patients were neurologically intact. The patient with persistent occlusion ultimately had moderate disability. Complications included the two cases of thrombotic occlusion that required a second operation, three cases of communicating hydrocephalus that required lumboperitoneal shunts, and two cases of transient dysfunction of the 9th and 10th cranial nerves. Suitable patients with persistent posterior circulation TIAs refractory to medical therapy who have appropriate angiographic evidence of proximal VA stenosis and poor collateral flow may benefit from endarterectomy of the intradural VA.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke

The annual incidence of stroke in the elderly approaches 2 per cent. The major tasks of the physician are to attempt to prevent recurrence and to supervise rehabilitation. Prevention of recurrence involves a careful consideration of differential diagnosis, treatment of contributory disease, and the initiation of therapy specific to large vessel infarction (atherothrombotic or cardiogenic embolic), lacunar infarction, or intracerebral hemorrhage. The high prevalence of lacunar infarction and the focal nature of posterior circulation transient ischemic attacks and strokes are not generally appreciated. Cardiogenic embolism due to atrial fibrillation and intracerebral hemorrhage due to congophilic angiopathy are of particular importance in the elderly. Treatment of stroke or transient ischemic attacks should be initiated quickly as the risk of recurrence is highest immediately following the signal event. History, neurologic and neurobehavioral examinations are important adjuncts in compensating for the inadequacy of CT and MRI in enabling the stroke classification necessary for proper treatment. Supportive care and rehabilitation can have a major impact on stroke morbidity and mortality and the management of risk factors can significantly reduce stroke incidence.

Vertebrobasilar insufficiency. Part 2. Microsurgical treatment of intracranial vertebrobasilar disease.

Posterior circulation transient ischemic attacks have an associated risk of subsequent infarction of approximately 5% per year. Intracranial vertebrobasilar thrombo-occlusive lesions appear particularly likely to result in repetitive ischemic symptoms and in infarction due to hemodynamic insufficiency. The authors present their experience with 45 patients with symptomatic intracranial vertebrobasilar vascular disease despite maximal medical therapy. The specific operative approaches for intracranial vertebral artery endarterectomy and extracranial to intracranial posterior circulation revascularization procedures are outlined.

Giant Cell Arteritis Causes Recurrent Posterior Circulation Transient Ischemic Attacks Which Respond to Corticosteroid

A 67-year-old man presented with recurrent clinically diverse posterior circulation transient ischemic attacks which continued despite full anticoagulation. Giant cell arteritis was suspected because of a markedly elevated erythrocyte sedimentation rate and confirmed by temporal artery biopsy. Treatment with corticosteroids resulted in a prompt and enduring resolution of clinical symptoms. Giant cell arteritis may represent a treatable cause of posterior circulation transient ischemic attacks, uniquely responsive to corticosteroids.

Life expectancy and late stroke following carotid endarterectomy.

A review of the UCSD experience with 456 consecutive carotid endarterectomy procedures confirms the acceptably low operative mortality and morbidity associated with this operation. Immediate complications were not different when routine or selective shunting was performed, but the patients with a low internal carotid artery back pressure had higher operative complication rates. The coexistence of atherosclerosis in other parts of the body severe-enough to warrant surgery for them was not associated with either higher early or late carotid surgery complication rates. Following both coronary bypass and carotid procedures, the late mortality was decreased, and the late incidence of stroke was particularly low in comparison to the remainder of the patient group. Late follow-up emphasized the high continuing attrition rate from all causes in these patients. Late strokes continued to occur, particularly in patients with prior strokes and severe preoperative bilateral carotid disease. The late course of patients with posterior circulation transient ischemic attacks treated by carotid endarterectomy was quite similar to that of patients treated for anterior circulation transient ischemia attacks (TIAs). Newer postoperative screening procedures may decrease the incidence of late postoperative stroke by identifying recurrent carotid stenosis while it is still in the asymptomatic stage.