Posterior Circulation Vessels Research Articles

Intravenous alteplase versus tenecteplase in patients with acute posterior circulation strokes: a secondary analysis from the AcT randomized controlled trial

ObjectivesThere are limited data available demonstrating the safety and efficacy of intravenous tenecteplase versus alteplase in patients with acute ischemic stroke in the posterior circulation. Materials and MethodsThis is a post-hoc analysis of the Alteplase compared to Tenecteplase(AcT) pragmatic, phase 3, registry-linked randomized controlled trial. Patients with any posterior circulation vessel occlusion on baseline imaging were included. Study outcomes included 90-day modified Rankin Scale(mRS) 0-1, mRS 0-2, ordinal mRS, death within 90 days, 24h symptomatic intracerebral haemorrhage(sICH) and successful reperfusion/recanalization. Mixed effects regression adjusting for age, sex and stroke severity was used to analyze differences in outcomes between patients administered tenecteplase vs. alteplase. Further, sensitivity analysis was conducted for basilar artery occlusion(BAO) alone. ResultsOf 1577 patients, 136(8.6%, 77:alteplase, 59:tenecteplase) had posterior circulation stroke. Baseline characteristics were similar[median age 71(IQR 60-81) vs. 72(IQR 65-82) years, 57.1% vs. 67.8% males, median baseline NIHSS 7(IQR 4-12) vs. 7(IQR 4-16) in alteplase vs. tenecteplase arms, respectively]. 28 patients(20.6%, 16:alteplase, 12:tenecteplase arm) underwent EVT. The median 90-120 days mRS was 2(IQR 1-4). There were no differences between alteplase and tenecteplase for 90-d mRS 0-1(adjRR 0.93;95%CI 0.63-1.36), 90-day mRS 0-2(adjRR 0.95; 95%CI 0.72-1.26), sICH(RR 0.65;95%CI 0.06-7.02) and mortality (RR 1.21;95%CI 0.61-2.38). Successful reperfusion eTICI 2b-3 and successful recanalization rAOL 2b-3 was achieved in 23/28(82%, 12:alteplase, 11:tenecteplase) and in 16/28(57%, 14:alteplase, 12:tenecteplase), respectively. Similar results were seen in 31 patients (22.8%) with BAO. ConclusionIntravenous tenecteplase has a similar effect on outcome as alteplase, without increased safety concerns in patients with acute posterior circulation strokes.

Vascular reconstruction related to the extracranial vertebral artery: the presentation of the concept and the basis for the establishment of the bypass system.

The intracranial vertebrobasilar artery system has a unique hemodynamic pattern (vessel trunk converged bilateral flow with three groups of perforators directly arising from it), is embedded within intense osseous constraints, and is located far from conventional donor vessels. Two major traditional modalities of posterior circulation revascularization encompass the superficial temporal artery to the superior cerebellar artery and the occipital artery to the posteroinferior cerebellar artery anastomosis, which are extracranial-intracranial low-flow bypass with donor arteries belonging to the anterior circulation and mainly supply focal perforators and distal vascular territories. As our understanding of flow hemodynamics has improved, the extracranial vertebral artery-related bypass has further evolved to improve the cerebral revascularization system. In this article, we propose the concept of "vascular reconstruction related to the extracranial vertebral artery" and review the design philosophy of the available innovative modalities in the respective segments. V1 transposition overcomes the issue of high rates of in-stent restenosis and provides a durable complementary alternative to endovascular treatment. V2 bypass serves as an extracranial communication pathway between the anterior and posterior circulation, providing the advantages of high-flow, short interposition grafts, orthograde flow in the vertebrobasilar system, and avoiding complex skull base manipulation. V3 bypass is characterized by profound and simultaneous vascular reconstruction of the posterior circulation, which is achieved by intracranial-intracranial or multiple bypasses in conjunction with skull base techniques. These posterior circulation vessels not only play a pivotal role in the bypass modalities designed for vertebrobasilar lesions but can also be implemented to revascularize the anterior circulation, thereby becoming a systematic methodology.

Teaching NeuroImages: Rupture and spontaneous resolution of a P1 perforator pseudoaneurysm

A 47-year-old man with a history of smoking and hypertension had a severe, sudden headache. Head CT showed subarachnoid hemorrhage (SAH) (figure, A). Progressive ophthalmoplegia developed without alteration of consciousness. Catheter angiography was normal (figure, B). Brain MRI documented bilateral thalamic infarcts (figure, C). Repeat catheter angiography after 4 days showed a 2-mm dissecting pseudoaneurysm of a thalamoperforator (figure, D and E). Serial noninvasive vascular studies documented no growth. Six weeks later, a catheter angiogram demonstrated complete resolution of the pseudoaneurysm (figure, F).Bilateral third nerve palsy persisted at 1 year follow-up. Dissecting pseudoaneurysms of perforating posterior circulation vessels can present with a pattern suggestive of perimesencephalic SAH. Presence of associated neurologic deficits should increase the level of suspicion. Spontaneous resolution can occur without invasive treatment.1

Abstract Number: LBA15 Transient Ischemic Attack Uncovering An Absent ICA

Introduction Absence of the Internal Carotid Artery (ICA) is a rare cerebrovascular anomaly signified by agenesis, aplasia, or hypoplasia of the ICA and its’ bony canal. Agenesis refers to complete absence whereas aplasia refers to some partial remanent of the ICA or the carotid canal however, these terms are often used interchangeably. There are 6 types of ICA agenesis/aplasia of which type A consists of collateral flow supplied to the MCA via the P‐comm and ACA via the A‐comm. The prevalence of such a condition is reported at around .01% of the population. Patients are usually asymptomatic due to robust collaterals but, in some cases, can present with focal neurologic deficits. Here, we present a case of a patient who endured a transient ischemic attack and was subsequently found to have type A Right ICA aplasia on cerebrovascular imaging. Methods Case Report Results A 24‐year‐old Right‐handed Female with no past medical history except for tobacco use presented with transient left arm monoparesis. The patient had received chiropractic treatment involving hyperextension of her neck to the left just prior to symptom onset which transiently caused her left arm to become plegic and she resolved back to her neurologic baseline within 10 minutes. Neurologic exam was normal and non‐contrast head CT was negative however, demonstrated significant hypoplasia of the right carotid canal (Figure 1‐A). Contrast enhanced CT Angiogram of the head and neck demonstrated lack of contrast opacification of the Right Internal Carotid artery with absent Right carotid bulb and opacification of only the Right ECA (Figure 1‐B). MRI of the brain did not demonstrate any acute infarction. Gadolinium enhanced MRA of the Head and Neck confirmed absence of the Right internal carotid (Figure 2‐A) with prominent Right P‐comm and absent Right A1 segment (Figure 2‐B). Due to this variant anatomy, the postulated mechanism of patient’s TIA was thought to be related to transiently decreased cerebral perfusion caused by partial mechanical compression of her vertebral arteries asymmetrically affecting the Right MCA distribution due to sole supply from the Right posterior communicating artery. Conclusions This case illustrates a fascinating variation from normal embryologic angiogenesis and highlights the importance of collateral blood flow through the circle of Willis in patient’s with congenitally absent internal carotid arteries. Particularly, this patient’s presentation demonstrates the risk that vascular compromise of posterior circulation vessels may play in patients with Type A ICA agenesis/aplasia and their subsequent risk of incurring transient ischemic events.

Comparative analysis of the combined petrosal and the pretemporal transcavernous anterior petrosal approach to the petroclival region.

The combined petrosal (CP) approach has been traditionally used to resect petroclival meningioma (PCM). The pretemporal transcavernous anterior petrosal (PTAP) approach has emerged as an alternative. A quantitative comparison of both approaches has not been made. This anatomical study compared the surgical corridors afforded by both approaches and identified key elements of the approach selection process. Twelve cadaveric specimens were dissected, and 10 were used for morphometric analysis. Groups A and B (n = 5 in each) underwent the CP and PTAP approaches, respectively. The area of drilled clivus, lengths of cranial nerves (CNs) II-X, length of posterior circulation vessels, surgical area of exposure of the brainstem, and angles of attack anterior and posterior to a common target were measured and compared. The area of drilled clivus was significantly greater in group A than group B (mean ± SD 88.7 ± 17.1 mm2 vs 48.4 ± 17.9 mm2, p < 0.01). Longer segments of ipsilateral CN IV (52.4 ± 2.33 mm vs 46.5 ± 3.71 mm, p < 0.02), CN IX, and CN X (9.91 ± 3.21 mm vs 0.00 ± 0.00 mm, p < 0.01) were exposed in group A than group B. Shorter portions of CN II (9.31 ± 1.28 mm vs 17.6 ± 6.89 mm, p < 0.02) and V1 (26.9 ± 4.62 mm vs 32.4 ± 1.93 mm, p < 0.03) were exposed in group A than group B. Longer segments of ipsilateral superior cerebellar artery (SCA) were exposed in group A than group B (36.0 ± 4.91 mm vs 25.8 ± 3.55 mm, p < 0.02), but there was less exposure of contralateral SCA (0.00 ± 0.00 mm vs 7.95 ± 3.33 mm, p < 0.01). There was no statistically significant difference between groups with regard to the combined area of the exposed cerebral peduncles and pons (p = 0.75). Although exposure of the medulla was limited, group A had significantly greater exposure of the medulla than group B (p < 0.01). Finally, group A had a smaller anterior angle of attack than group B (24.1° ± 5.62° vs 34.8° ± 7.51°, p < 0.03). This is the first study to quantitatively identify the advantages and limitations of the CP and PTAP approaches from an anatomical perspective. Understanding these data will aid in designing maximally effective yet minimally invasive approaches to PCM.

Cerebrovascular Complications After Adult-Onset Varicella-Zoster Virus Encephalitis in the Central Nervous System: A Literature Review.

BackgroundCerebrovascular complications after adult-onset varicella-zoster virus (VZV) encephalitis have been increasingly recognized. The aim of this study was to analyze clinical and neuroimaging findings, treatment and outcome of these patients.MethodsLiterature review from January 2000 to December 2019. We searched for studies published in PubMed, Embase and Chinese Biomedical Literature Database. Clinical symptoms, neuroimaging findings, treatment and outcome were evaluated.ResultsWe analyzed 31 articles with a total of adult-onset 34 cases, including 25 cases of ischemic stroke, 6 of intracerebral hemorrhage and 3 with venous sinus thrombosis. Ischemic stroke was the major complication after VZV encephalitis accounting of 73.35%. There were more males than females in ischemia or venous sinus thrombosis groups. The middle-aged was prone to cerebral infarction, the elderly was for cerebral hemorrhage, and the young was for venous sinus thrombosis. Cognitive impairment was the most common symptom either in the ischemic group or hemorrhagic group. The lesions of VZV-associated cerebral infarction or hemorrhage were multifocal and mostly involved in the parietal lobe, followed by frontal or temporal lobes. Venous sinus thrombosis was common in the transverse sinus. Multiple stenosis of the anterior and posterior circulation vessels was found. A 60.87% of the patients with antiviral treatment in the ischemic group had favorable prognosis. All patients with anticoagulant therapy in venous sinus thrombosis group improved well; however, 60% of the patients with intracerebral hemorrhage had a poor prognosis or died.ConclusionIschemic stroke was the majority of cerebrovascular complications after VZV encephalitis, which mainly occurred in middle-aged men. The lesions of VZV-associated cerebral infarction or hemorrhage were multifocal and did not accord with the characteristics of cerebrovascular diseases induced by atherosclerosis. The patients with venous sinus thrombosis had a relatively good prognosis. When the patient represents with some neurological symptoms about one month after VZV encephalitis, and multiple lesions probably induced by vasculitis are showed in neuroimaging, cerebrovascular complications related to VZV infection should be considered.

Analysis of posterior circulation diameters depending on age, sex and side by computed tomography angiography.

Posterior circulation of brain is important because of vital organs' blood supply provided by them. In this study, we evaluate the relationship of posterior circulation measurements with age, gender and side by using computed tomography angiography (CTA) images. A total 199 brain CTA examinations were retrospectively analysed for all posterior circulation arteries (vertebral artery, basilar artery, posterior cerebral artery [PCA], superior cerebellar artery [SCA], anterior inferior cerebellar artery, and posterior inferior cerebellar artery [PICA]) to compare the difference based on age, gender and side. There is no correlation between age and the mean diameters of all vessels (p > 0.05). The mean diameter of left vertebral artery was higher than right vertebral artery in all genders (p = 0.004 for males and p < 0.001 for females). The mean diameter of left SCA and PICA were higher than right SCA and PICA in females (p = 0.032 and p = 0.027, respectively). The mean diameters of basilar, left PCA, left SCA, left vertebral, right PCA, right SCA, right PICA and right vertebral artery were higher in males and that differences were statistically significant (p < 0.001, p = 0.002, p = 0.006, p = 0.004, p = 0.001, p = 0.003, p = 0.002, and p = 0.006, respectively). The posterior circulation vessel diameter is not affected by aging. The mean diameters of basilar artery, both PCAs, both SCAs, right PICA, both vertebral arteries were higher in males. The mean diameter of left vertebral artery is higher than that of right vertebral artery in all genders.

Optimized Hemodynamic Assessment to Predict Stroke Risk in Vertebrobasilar Disease: Analysis From the VERiTAS Study.

BackgroundAtherosclerotic vertebrobasilar disease is a significant etiology of posterior circulation stroke. The prospective observational VERiTAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) study demonstrated that distal hemodynamic status is a robust predictor of subsequent vertebrobasilar stroke risk. We sought to compare predictive models using thresholds for posterior circulation vessel flows standardized to age and vascular anatomy to optimize risk prediction.Methods and Results VERiTAS enrolled patients with recent vertebrobasilar transient ischemic attack or stroke and ≥50% atherosclerotic stenosis/occlusion in vertebral and/or basilar arteries. Quantitative magnetic resonance angiography measured large‐vessel vertebrobasilar territory flow, and patients were designated as low or normal flow based on a prespecified empiric algorithm considering distal territory regional flow and collateral capacity. For the present study, post hoc analysis was performed to generate additional predictive models using age‐specific normalized flow measurements. Sensitivity, specificity, and time‐to‐event analyses were compared between the algorithms. The original prespecified algorithm had 50% sensitivity and 79% specificity for future stroke risk prediction; using a predictive model based on age‐normalized flows in the basilar and posterior cerebral arteries, standardized to vascular anatomy, optimized flow status thresholds were identified. The optimized algorithm maintained sensitivity and increased specificity to 84%, while demonstrating a larger and more significant hazard ratio for stroke on time‐to‐event analysis.ConclusionsThese results indicate that flow remains a strong predictor of stroke across different predictive models, and suggest that prediction of future stroke risk can be optimized by use of vascular anatomy and age‐specific normalized flows.

Endovascular Thrombectomy for Acute Ischemic Stroke.

To review the current evidence supporting the use of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO). Recent advances in AIS management by EVT have led to significant reduction in morbidity and mortality in selected patients with LVO within the anterior circulation. Until recently, use of EVT was strictly based on time criteria, within 4.5 to 12h of symptom onset with many patients presenting with "wake-up" stroke who were not considered for EVT. The positive results of the DAWN and DEFUSE-3 trials have shown benefit in extending the therapeutic window for EVT to 24 and 16h, respectively, after last known normal (LKN) time in the setting of large ischemic penumbra. These trials represent a paradigm shift in contemporary treatment of AIS, changing from a purely time-based decision to treat to an individualized decision based on clinical and radiographic findings of salvageable tissue. Overall, acute stroke management has evolved considerably over the years from intravenous thrombolysis to include EVT, with paralleled improvements in patient selection and thrombectomy devices. Since the results of the DAWN and DEFUSE-3, EVT is now considered the standard of care in select patients with anterior circulation LVO up to 24h from LKN time. Despite these developments, post-stroke disability remains pervasive and further studies are warranted in establishing the role of EVT in posterior circulation and distal vessel occlusions, with need for development of new and effective techniques for revascularization of small vessels.

Brain CT perfusion improves intracranial vessel occlusion detection on CT angiography

Background and purposeTo evaluate whether brain CT perfusion (CTP) aids in the detection of intracranial vessel occlusion on CT angiography (CTA) in acute ischemic stroke. Materials and methodsMedical-ethical committee approval of our hospital was obtained and informed consent was waived. Patients suspected of acute ischemic stroke who underwent non-contrast CT(NCCT), CTA and whole-brain CTP in our center in the year 2015 were included. Three observers with different levels of experience evaluated the imaging data of 110 patients for the presence or absence of intracranial arterial vessel occlusion with two strategies. In the first strategy, only NCCT and CTA were available. In the second strategy, CTP maps were provided in addition to NCCT and CTA. Receiver-operating-characteristic (ROC) analysis was used for the evaluation of diagnostic accuracy. ResultsOverall, a brain perfusion deficit was scored present in 87–89% of the patients with an intracranial vessel occlusion, more frequently observed in the anterior than in the posterior circulation. Performance of intracranial vessel occlusion detection on CTA was significantly improved with the availability of CTP maps as compared to the first strategy (P=0.023), due to improved detection of distal and posterior circulation vessel occlusions (P-values of 0.032 and 0.003 respectively). No added value of CTP was found for intracranial proximal vessel occlusion detection, with already high accuracy based on NCCT and CTA alone. ConclusionThe performance of intracranial vessel occlusion detection on CTA was improved with the availability of brain CT perfusion maps due to the improved detection of distal and posterior circulation vessel occlusions.

Vascular complications in transsphenoidal surgery

Objectives: Vascular complications can and do arise fromtranssphenoidal surgery and, when occur, they have a highincidence of mortality and serious morbidity. The anatomicsubstrate for such complications is discussed, along with technicalaspects of surgery and other methods for the avoidanceof vascular complications. The aim of this paper is discuss themain vascular complications of transsphenoidal approach. Methods: The authors retrospectively analyzed the data regarding4175 pituitary transsphenoidal operations from 1974to 2004. Results: Thirty-four (34) patients (0.8%) developed directvascular complications from transsphenoidal surgery. Nine (0.2 %) of these were fatal. Conclusions: Intra-operative injury of the carotid artery is predominately associated with microadenomas, basilar perforatorinjury may be associated with invasive macroadenomasand anterior cerebral artery injury may be associated withsupra- sellar tumors. Regarding outcomes, injury of anteriorcirculation vessels shows relatively low morbidity and mortality,and injury to posterior circulation vessels shows relativelyhigh morbidity and mortality.

Fenestra Obscura: Flow Diverter Reconstruction of a Complex Vertebrobasilar Aneurysm Through an Obscured Fenestration Limb: Technical Case Report.

Basilar fenestration aneurysms are rare, challenging intracranial vascular lesions with atypical anatomy. The posterior circulation represents a difficult therapeutic dilemma because of the close proximity of crucial life-sustaining brainstem structures. The use of flow diverter technology has been very limited in posterior circulation vessels. We present the case of a 49-year-old female patient, who was diagnosed with a symptomatic large vertebrobasilar junction aneurysm, which was initially thought to be a proximal basilar dilatation. The aneurysm was later verified to arise from the proximal end of a basilar fenestration, distended by the aneurysm fundus. The small-caliber fenestration limbs were the only connection to the distal basilar artery, but were stretched laterally and concealed by the aneurysm fundus. This complex lesion was successfully treated by flow diverter deployment through one of the fenestration limbs, followed by coiling of the aneurysm fundus, and sacrificing the contralateral vertebral artery. A 6-month follow-up angiogram showed remodeling of the basilar artery and complete occlusion of the aneurysm with good clinical outcome. Careful diagnostic workup, multidisciplinary discussions, and the innovative use of versatile endovascular technology were crucial to achieve an optimal result in this case. This is the first report of a successful basilar artery reconstruction for the treatment of a large atypical vertebrobasilar junction fenestration aneurysm by deployment of a flow diverter device directly in a small, obscured fenestration limb.

The application value of TCD combined with CDUS in the large artery atherosclerosis

Objective: To explore the value of TCD and CDUS on diagnosis of large artery atherosclerosis. Methods: In our study, 90 patients who had been admitted to our hospital and diagnosed as LAA according to CISS typing were selected as the research object. A retrospective analysis was conducted, using CTA as golden standard for diagnoses of stenoses. Explore the risk factors of LAA, the reliability of TCD and CDUS in diagnosis of the stenosis and distribution of stenosis in each vessel. Results: Hypertension and type 2 diabetes are risk factors of LAA vascular stenosis. Middle cerebral artery stenosis detection by TCD carries the highest reliability (sensitivity 90.91%, specificity 97.89%, positive predictive value 96.15%, the negative predictive value was 94.9%, the positive likelihood ratio was 43.18, negative likelihood ratio 0.09, Kappa = 0.9). The consistency of TCD is as good as CTA in head and neck part. The negative coincidence rate was higher in the anterior circulation vessels (97.98%), followed by the coincidence rate of severe stenosis (95.23%). However, the detection rate of posterior circulation vessels positive, moderate and severe stenosis, mild stenosis gradually decreased by TCD. CDUS carries general reliability in detecting intracranial extracranial stenosis, the highest reliability in internal carotid artery (kappa 0.82), and the worst consistency in vertebral artery (kappa 0.38). The negative coincidence rate of CDUS in extracranial cerebrovascular stenosis was highest (97.22), followed by the overall compliance rate (91.55%). 242 branches of vascular stenosis were discovered in our study, among which intracranial artery stenosis 61.15% (148/242) is higher than that in extracranial artery 38.85% (90/242), ratio of moderate to severe stenosis is as high as 82.23% (199/242). Intracranial artery stenosis in ICA is extremely common (51.11%, 46/90), and MCA is the common area of intracranial artery stenosis (37.16%, 55/148). Conclusions: (1) Hypertension, type 2 diabetes are risk factors for LAA stenosis. (2) TCD detection of intracranial vascular stenosis carries the best consistency, and reliability of MCA is the highest. In our search, MCA possesses the highest rate of stenosis, and negative coincidence rate by TCD examination was the highest, which could be used for screening method for stenosis. The reliability of TCD in diagnosis of moderate and severe stenosis was relatively better than mild stenosis. (3) CDUS detection of anterior circulation lesions is better than that of posterior circulation lesions. Evaluate effect on moderate and severe stenosis was better than that of mild one. The ratio of ICA stenosis was the highest, but the effect on VA was poor. (4) The incidence of intracranial vascular stenosis is more common than that of the intracranial vascular stenosis.

Hemodynamic Features of Symptomatic Vertebrobasilar Disease

Atherosclerotic vertebrobasilar disease is an important cause of posterior circulation stroke. To examine the role of hemodynamic compromise, a prospective multicenter study, Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS), was conducted. Here, we report clinical features and vessel flow measurements from the study cohort. Patients with recent vertebrobasilar transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral or basilar arteries (BA) were enrolled. Large-vessel flow in the vertebrobasilar territory was assessed using quantitative MRA. The cohort (n=72; 44% women) had a mean age of 65.6 years; 72% presented with ischemic stroke. Hypertension (93%) and hyperlipidemia (81%) were the most prevalent vascular risk factors. BA flows correlated negatively with percentage stenosis in the affected vessel and positively to the minimal diameter at the stenosis site (P<0.01). A relative threshold effect was evident, with flows dropping most significantly with ≥80% stenosis/occlusion (P<0.05). Tandem disease involving the BA and either/both vertebral arteries had the greatest negative impact on immediate downstream flow in the BA (43 mL/min versus 71 mL/min; P=0.01). Distal flow status assessment, based on an algorithm incorporating collateral flow by examining distal vessels (BA and posterior cerebral arteries), correlated neither with multifocality of disease nor with severity of the maximal stenosis. Flow in stenotic posterior circulation vessels correlates with residual diameter and drops significantly with tandem disease. However, distal flow status, incorporating collateral capacity, is not well predicted by the severity or location of the disease.

PP04.13 – 2780: The association of Moya Moya disease with pseudocoarctation: A case report

Objective Moya Moya disease is characterized by the progressive occlusion of the cerebral arteries at the circle of Willis, leading to formation of abnormal networks of small collateral vessels with a “puff of smoke” appearance on angiography. The classic pattern involves the distal internal carotid arteries bilaterally, but unilateral variants and involvement of additional anterior and posterior circulation vessels are well described. Coarctation of aorta is a rare association in Moya Moya disease. We present a case of Moya Moya disease and pseudocoarctation of aortic arch. Methods A 7-year-old girl was admitted with a brief loss of consciousness. History revealed clumsyness and frequent falls. All her developmental milestones were delayed comparing peers. Physical examination revealed slight left sided hemiparesis, dysmetria and dysdiadokinesia on the left side. Her EEG was normal. Brain magnetic resonance imaging (MRI) showed encephalomalacia in the right occipital lobe and conventional cerebral angiography revealed occlusion in several arteries including bilateral internal carotid arteries, bilateral anterior cerebral arteries, and bilateral posterior cerebral arteries and diffuse collateral vessels with a puff of smoke appearance. In echocardiographic study, aortic arch and isthmus was tortous, a gradient of 45 mmHg was measured between the proximal and distal parts of coarctation site by CW Doppler. Coarctation of aorta was suggested. Catheter angiography showed large dilated aortic arch kinking at before origin of left subclavian artery, without any pressure difference between the proximal and distal parts, pseudocoarctation was diagnosed. Aspirin was started for prevention of subsequent cerebral embolism. Results The diagnosis of Moya Moya disease was made based on conventional cerebral angiography findings. Conclusion The association of Moya Moya disease with aortic pseudocoarctation may be related to an extensive systemic involvement of blood vessels. Careful evaluation of children with Moya Moya disease is necessary to detect aortic coarctation.

Abstract T P18: Incidence and Management of Intracranial Wire Perforation During Acute Stroke Endovascular Therapy

BACKGROUND: Wire perforation during endovascular thrombectomy for acute stroke is a rare but devastating complication. Understanding the incidence and mechanism of this adverse event may further identify preventive strategies and improvements in management during perforation. METHODS: Retrospective review of a prospectively maintained database of acute stroke interventions at our institute identified 1035 patients. Of these, 46 patients were noted to have contrast extravastion during the procedure concerning for wire perforation (4%). RESULTS: A majority of the cases involved the anterior circulation (76%). Sites of perforation included: ICA (12), MCA (23), ophthalmic (1), anterior choroidal (2), PCA (4), PICA (1), SCA (1) and vertebral artery (2). Successful hemostasis was achieved with onyx embolization (39%), coil embolization (13%), onyx/coil combined embolization (5%), microcatheter occlusion (2%) and balloon inflation (7%). Thirty one percentage of the cases occurred during intracranial stenting or angioplasty. Despite high rates of mortality (72%), rapid recognition of extravasation and hemostasis led to good outcomes in 9% of patient. CONCLUSION: Intra-procedural wire perforation with leakage of contrast is associated with catheterization of small caliber vessels such as distal MCA branches (M3), anterior choroidal artery and diminutive posterior circulation vessels as well as intracranial angioplasty/stenting. Devastating outcomes can potentially be averted with appropriate hemostatic control.

Abstract 14021: Angiographic and Hemodynamic Features of Symptomatic Vertebrobasilar Disease: Baseline Data from the VERiTAS Study

Introduction: Atherosclerotic vertebrobasilar disease (VBD) is a significant etiology of posterior circulation stroke. In addition to thromboembolism, regional hypoperfusion is considered an important potential contributor to stroke risk. To examine the role of hemodynamic compromise in VBD, a prospective observational multi-center study, Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS), has recently been conducted. Here we report baseline features and vessel flow measurements from the study cohort. Methods: Baseline demographic and clinical data was collected in patients with recent vertebrobasilar TIA or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral and/or basilar arteries. Large vessel flow in the vertebrobasilar territory was assessed using quantitative MRA (QMRA). Results: The cohort (n=75, 56% male) had a mean age of 65.5 (range 40 to 90) years; two thirds presented with ischemic stroke. Hypertension (93%) and hyperlipidemia (79%) were the most prevalent vascular risk factors. Vertebral and basilar artery flows correlated negatively with degree of stenosis in the affected vessel, and positively to the minimal diameter at the site of stenosis (p&lt;0.01). A threshold effect was evident, with affected vessel flows dropping significantly in patients with ≥70% stenosis or occlusion (p&lt;0.05). Tandem disease involving the basilar and either or both the vertebrals had the greatest impact on immediate downstream flow in the basilar artery (38 ml/min vs. 74 ml/min, p&lt;0.01). Assessment of distal flow status, incorporating collateral flow, however correlated neither with multifocality of disease nor severity of the maximal stenosis. Conclusions: Flow in stenotic posterior circulation vessels correlate with residual diameter and stenosis and drop significantly in the setting of tandem disease. However, distal flow status, incorporating collateral capacity, is not well predicted by the severity or location of the disease. Final clinical outcome results from the ongoing VERiTAS study will further clarify the relevance of anatomic stenosis and hemodynamic assessment to predicting stroke risk in patients with vertebrobasilar disease.

Posterior circulation flow diversion: a single-center experience and literature review

BackgroundFlow diverters have been used predominantly for large anterior circulation aneurysms. Data on the safety and efficacy of this treatment for posterior circulation aneurysms are limited.ObjectiveTo present our posterior circulation...

P-022 Flow Diversion in the Posterior Circulation: A Single Center Experience and Literature Review

IntroductionFlow diverters have been increasingly utilised for the treatment of large intracranial aneurysms, predominantly in the anterior circulation. There is limited data available on the safety and efficacy of this...

Comparison of Carotid and Cerebrovascular Stenosis between Diabetic and Nondiabetic Patients Using Digital Subtraction Angiography

The aim of our study was to evaluate the differences of prevalence and manifestation of extracranial and intracranial artery stenosis between patients with and without type 2 diabetes using digital subtraction angiography. A retrospective study was conducted by analyzing clinical and lifestyle data collected from 1137 patients enrolled in the Nanjing Stroke Registry Program between June 2004 and March 2011. Vascular risk factors were analyzed, and carotid and cerebrovascular artery stenoses were measured in 383 patients with type 2 diabetes mellitus and 754 nondiabetic patients by digital subtraction angiography. In all, 1069 stenoses were found among 383 diabetic patients and 1990 among 754 nondiabetic patients. No statistical differences were observed for the distribution of stenosis in intracranial-extracranial vessels between diabetic and nondiabetic patients (P=.210). There was no difference in the distribution of stenosis in the anterior and posterior circulation vessels between these 2 groups (P=.628). Among diabetic patients with stenosis, a single stenosis was found in 116 (30.29%) and multiple stenoses were found in 267 (69.71%). In their nondiabetic counterparts, a single stenosis was found in 249 (33.02%) and multiple stenoses were found in 505 (66.98%). Compared with nondiabetic patients, the diabetic patients have a tendency of a higher incidence of multiple stenosis. Nonobstructive stenosis occurs more often in diabetic than in nondiabetic patients (P=.002). This retrospective study suggests that diabetes be associated with higher incidence of nonobstructive stenosis and that there be no significant difference observed in the extent and distribution of the extra- and intracranial artery stenoses between diabetic and nondiabetic patients.