Symptomatic Vertebral Artery Research Articles

Stenting vs. Medical Management for Vertebral Artery Stenosis

Although patients with symptomatic vertebral artery stenosis have a high risk for recurrent stroke, and stenting of extracranial or intracranial

Stenting for symptomatic vertebral artery stenosis: a preplanned pooled individual patient data analysis

Symptomatic vertebral artery stenosis is associated with a high risk of recurrent stroke, with higher risks for intracranial than for extracranial stenosis. Vertebral artery stenosis can be treated with stenting with good technical results, but whether it results in improved clinical outcome is uncertain. We aimed to compare vertebral stenting with medical treatment for symptomatic vertebral stenosis. We did a preplanned pooled individual patient data analysis of three completed randomised controlled trials comparing stenting with medical treatment in patients with symptomatic vertebral stenosis. The primary outcome was any fatal or non-fatal stroke. Analyses were performed for vertebral stenosis at any location and separately for extracranial and intracranial stenoses. Data from the intention-to-treat analysis were used for all studies. We estimated hazard ratios (HRs) with 95% CIs using Cox proportional-hazards regression models stratified by trial. Data were from 354 individuals from three trials, including 179 patients from VIST (148 with extracranial stenosis and 31 with intracranial stenosis), 115 patients from VAST (96 with extracranial stenosis and 19 with intracranial stenosis), and 60 patients with intracranial stenosis from SAMMPRIS (no patients had extracranial stenosis). Across all trials, 168 participants (46 with intracranial stenosis and 122 with extracranial stenosis) were randomly assigned to medical treatment and 186 to stenting (64 with intracranial stenosis and 122 with extracranial stenosis). In the stenting group, the frequency of periprocedural stroke or death was higher for intracranial stenosis than for extracranial stenosis (ten (16%) of 64 patients vs one (1%) of 121 patients; p<0·0001). During 1036 person-years of follow-up, the hazard ratio (HR) for any stroke in the stenting group compared with the medical treatment group was 0·81% CI 0·45-1·44; p=0·47). For extracranial stenosis alone the HR was 0·63 (95% CI 0·27-1·46) and for intracranial stenosis alone it was 1·06 (0·46-2·42; pinteraction=0·395). Stenting for vertebral stenosis has a much higher risk for intracranial, compared with extracranial, stenosis. This pooled analysis did not show evidence of a benefit for stroke prevention for either treatment. There was no evidence of benefit of stenting for intracranial stenosis. Stenting for extracranial stenosis might be beneficial, but further larger trials are required to determine the treatment effect in this subgroup. None.

Abstract TP155: Comparison Between Medical Therapy and Endovascular Treatment of the Extracranial Atherosclerotic Vertebral Artery Disease: A Systematic Review

Objective: To assess the potential benefit of endovascular treatment compared to medical treatment in patients with symptomatic extracranial vertebral artery (ECVA) atherosclerotic disease in terms of clinical outcomes through a systematic literature review of published reports. Methods: We identified ECVA studies published between January 1966 and December 2017 using a search on PubMed and Cochrane libraries supplemented by review of bibliographies of selected publications based on pre-specified criteria. The rates of stroke and stroke and/or death were estimated for best medical treatment and endovascular treatment, at 1 month and at last follow-up. A random effects model was used to calculate pooled proportions (PP) across all studies and 95% confidence intervals. Results: Of a total of 57 reports reviewed, 8 studies reported outcomes in patients receiving medical treatment only (362 patients) and 49 studies reported upon patients treated with endovascular approach (2142 patients). The mean age of patients in the medical group was 65.6 years (range 61.3 - 69.0 years) and 64.1 years (range 53.5 - 72 years ) in the endovascular group. The 30 day incidence of stroke was 26 (7.2%) in the medical treatment group compared to 18 (0.84%) in the endovascular group, resulting in a higher risk for patients in the best medical treatment when compared to endovascular treatment [PP 0.0559 vs. 0.0025; p-value = 0.0001)]. Similarly at follow-up, 33 (12.3 %) stroke were observed in the medical group compared to 51(2.4 %) in the endovascular group [PP 0.1027 vs. 0.0109 ; p-value = 0.0001)].There was also statistically difference in stroke related death in the medical group vs endovascular group 12 (4.5 % ) vs 1 (0.04% ) [PP 0.03309 vs. 0.0000 ;p-value =0.001] . There was no statistically significant difference in the rates of recurrent TIA or death to other causes between the two groups. Conclusion: Our analysis demonstrated that endovascular treatment significantly reduced the risk of stroke and death when compared to best medical treatment alone at 30 days and at follow-up. Randomized clinical trial is warranted for further understanding of the safety and efficacy of the endovascular treatment.

A12181 Effect of Stenting on Blood Pressure in Hypertensive Patients with Symptomatic Proximal Subclavian or Vertebral Artery Stenosis

Objectives: To evaluate the effect of posterior circulation revascularization on blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. Methods: 48 patients with essential hypertension (33 males; mean age 63.0 ± 8.7 years) with symptomatic proximal subclavian or vertebral artery stenosis (diameter reduction≥70%), who underwent successful stenting on the lesions, were prospectively enrolled at Fuwai Hospital between January 2014 and December 2015. These were followed up at 1, 3 and 6 months after the procedure. During the study, antihypertensive agents and dosage were fixed, Blood pressure and complications were investigated. Results: Baseline office blood pressure (OBP) of 132/77 ± 10/8 mm Hg, 24-hour ambulatory blood pressure (ABP) of 127/75 ± 12/9 mm Hg, and mean of 1.6 ± 0.8 antihypertensive agents. The mean subclavian and vertebral artery stenosis decreased from 88.9 ± 9.5% and 85.8 ± 7.4% to5.5 ± 3.5% and 4.6 ± 3.7% immediately after stenting, respectively. Mean reductions in OBP were –7/–3 (95% CI 3/2), –9/–4 (5/3), and –10/–5 mm Hg (7/5) at 1, 3, and 6 months, respectively. 24-h ABP after the procedure were reduced by –5/–3 mm Hg at 6 months. No procedure related complications occurred. Conclusion: This first prospective cohort study in human showed posterior circulation revascularization appears to be effective in reducing blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. However, the finding should be confirmed further.

A11105 Effect of Posterior Circulation Revascularization on Blood Pressure in Hypertensive Patients

Objectives: To evaluate the effect of posterior circulation revascularization on blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. Methods: A total of 48 patients with essential hypertension (33 males; mean age 63.0 ± 8.7 years) with symptomatic proximal subclavian or vertebral artery stenosis underwent stenting successfully at the Fuwai Hospital were prospectively enrolled in the study between January 2014 and June 2016. All 48 patients were followed up at 1, 3 and 6 months after the procedure. Blood pressure, use of antihypertensive agents, and complications were investigated. Results: Baseline values included mean office blood pressure of 132/77 ± 10/8 mm Hg, 24-hour mean blood pressure of 127/75 ± 12/9 mm Hg, and mean 1.6 ± 0.8 antihypertensive agents. The mean stenosis of subclavian and vertebral artery decreased from 88.9 ± 9.5% and 85.8 ± 7.4% to 5.5 ± 3.5% and 4.6 ± 3.7% immediately after the procedure, respectively. Mean reductions in office blood pressure were −7/−3 (95% CI 3/2), −9/−4 (5/3), and −10/−5 mm Hg (7/5) at 1, 3, and 6 months, respectively. 24-hour mean blood pressures after procedure were reduced by −5/−3 mm Hg at 6 months, and the total number of antihypertensive agents at the above corresponding time points essentially unchanged. Conclusion: This first prospective cohort study in human showed posterior circulation revascularization seems to be effective in reducing blood pressure in hypertensive patients. Our research outcome validates the results of previous animal experiments, suggesting the Cushing's mechanism play an important role in the long-term control of mean arterial pressure of human.

Unplanned 30-Day Hospital Readmissions of Symptomatic Carotid and Vertebral Artery Dissection.

Unplanned 30-Day Hospital Readmissions of Symptomatic Carotid and Vertebral Artery Dissection.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Cervical Spine Trauma: 24. Cervical angiograms in cervical spine trauma patients five years after the data: has practice changed?

BACKGROUND CONTEXT Advanced diagnostic imaging utilizing CT technology has made angiography easier and faster to obtain in the trauma setting. Prior studies have shown that the rates of symptomatic vertebral artery injuries (VAI) are relatively low in the trauma population, approximately 0.1%, but that screening a broader population of asymptomatic trauma patients can increase the rate of injuries diagnosed to near 1%2. While CT angiography (CTA) can readily provide a diagnosis, clinical significance of a positive result in polytrauma patients is limited by the high number of concomitant injuries and limit the number of patients who are candidates for therapeutic anticoagulation or other treatments. PURPOSE At our institution, this had been described in a previous five-year study and the information disseminated between trauma attending physicians and the orthopedic department. We sought to retrospectively evaluate the patterns use of CTA in the trauma population at the authors’ institution for the five years after this intervention was taken to evaluate for changes in practice. STUDY DESIGN/SETTING Retrospective observational study at a Level 1 trauma hospital. PATIENT SAMPLE A total of 1,201 charts from 2011 to 2016 were reviewed including all level 1 and 2 trauma patients with cervical spine complaints and 1,142 subjects were eligible for inclusion. This time frame begins after the prior referenced study by Dreger et al was completed and results of the study had been disseminated among the trauma and orthopedic faculty OUTCOME MEASURES Outcome measures were positive CTA study, and treatment for diagnosed vertebral artery injury. METHODS A total of 1,201 charts were reviewed. A total of 1,142 subjects were eligible for inclusion, and 187 subjects underwent CTA/MRA. A total of 640 patients had cervical spine fractures, and of these 158 patients had CTA/MRA. Inclusion criteria were ages 18-89, and imaging of the cervical spine performed. Exclusion criteria were ballistic or penetrating trauma to the neck, death on arrival to the emergency department without imaging performed, and imaging performed at outside institution only. Statistical analysis was performed using SPSS. RESULTS Twenty-four patients were diagnosed with VAI, and 12 were treated for these findings. None of the subjects treated had complications from angiography, one patient with VAI had increased blood loss after initiation of therapeutic anticoagulation requiring transfusion. There has been a significant increase in CTA/MRA testing done at our institution (P CONCLUSIONS Despite discussion at our institution of the clinical utility of CTA in the trauma population, there are more CTA studies being done and the number of patient's diagnosed and treated for VAI have not changed. The presence of symptoms and risk of bleeding or other complications of therapeutic anticoagulation in this population are important factors to consider when ordering this test. We recommend the use of a treatment algorithm in the electronic ordering system to help aid practitioners in targeting the use of this test. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Long-Term Risk of In-Stent Restenosis and Stent Fracture for Extracranial Vertebral Artery Stenting.

Stenting and angioplasty of the vertebral artery (VA) is used to treat symptomatic stenosis but the long-term outcomes and complications are unclear. This study evaluated the long-term clinical outcomes and procedure-related complications in patients who underwent extracranial VA stenting and angioplasty, in particular the risks of in-stent restenosis (ISR) and stent fracture. This was aretrospective review of consecutive patients suffering from symptomatic extracranial VA stenosis who were treated with balloon-expandable bare metal stents. The clinical and angiographical outcomes were reviewed for procedural complications, recurrent stroke, ISR and stent fracture. In this study 22patients (17male, 5female) with amean age of 63.4years (SD9.1years) were included. The median follow-up was 56months (interquartile range IQR 51.8months). There were no periprocedural complications. The cumulative ISR risk was 45% with 6cases detected at 1year and 3cases detected at 3years post operation. The cumulative stent fracture rate at 1year, 3years, 5years and the entire follow-up period were 5%, 15%, 25%, and 30%, respectively. Posterior circulation stroke occurred in 1patient (4.5%), and 3patients died of non-cerebrovascular causes during follow-up. Of the patients 2 with ISR and stent fracture required additional treatment. The long-term ISR and stent fracture risks were high in extracranial VA stenosis treated with balloon-expandable bare metal stents. The risk of stent fracture increased over time during the follow-up period. Further studies should be conducted to clarify the long-term safety and efficacy of extracranial VA stenting.

Effects of endovascular stent implantation and medical treatment on symptomatic vertebral artery stenosis

Objective To investigate the clinical effect of endovascular stent implantation and medical treatment in the treatment of symptomatic vertebral artery stenosis. Methods Eighty patients with symptomatic vertebral artery stenosis admitted from January 2013 to May 2015 in the Department of Neurology of Wuhan Puren Hospital were selected.The patients were randomly divided into the observation group and the control group, with 40 cases in each group.The control group was given aspirin enteric-coated tablets 100 mg/ time, 1 time /d, clopidogrel bisulfate bablets 75 mg/ time, 1 time /d, atorvastatin calcium 10 mg/ time, 1 time/d.The observation group was treated with intravascular stent implantation.After 1 years of follow-up, the degree of vascular stenosis, the occurrence of ischemic cerebrovascular time and the clinical effect of the two groups were compared. Results (1) The stenosis degree of the observation group and the control group before treatment was (72.81±11.99)% and (68.31±12.35)% respectively, after treatment, it was (24.58±1.24)% and (56.01±3.30)% respectively.There was no significant difference between the two groups before treatment (t=0.121, P>0.05). After treatment, vascular stenosis degree in two groups were significantly improved, compared with that before treatment, the differences were statistically significant (t=0.790, P<0.05; t=0.457, P<0.05); the degree of vascular stenosis after treatment in the observation group was significantly lower than that in the control group (t=0.842, P<0.05); (2) during follow-up, the total occurrence rate of ischemic cerebrovascular events in the observation group was 17.5% (7/40), compared to 37.5% (15/40) in the control group, the difference between the two groups was statistically significant (χ2=4.065, P<0.05). (3) At 1 years of follow-up, the total effective rate of the observation group was 97.5% (39/40), while that of the control group was 60% (24/40), and the difference between the two groups was statistically significant (P=0.017). Conclusion Endovascular stent implantation can effectively improve the clinical efficacy of symptomatic vertebral artery, reduce the incidence of ischemic cerebrovascular time, and improve the degree of vascular stenosis. Key words: Intravascular stent implantation; Symptomatic vertebral artery stenosis; Aspirin enteric-coated tablets; Clopidogrel sulfate; Atorvastatin calcium

Stenting for Symptomatic Vertebral Artery Stenosis: The Vertebral Artery Ischaemia Stenting Trial

Objective: To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis. Methods: VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant. Results: Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05). Conclusions: Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk. ISRCTN.com identifier: ISRCTN95212240. Classification of evidence: This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.

Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: Experience of a single center and review of literature

ObjectiveThe optimal treatment of chronic symptomatic total occlusion of the intracranial vertebral artery (ICVA) remains undefined. We report a single-center experience of endovascular recanalization for patients with chronic symptomatic ICVA occlusion who were refractory to medical therapy. MethodsFrom Jan 2009 to Jan 2017, we retrospectively reviewed 14 consecutive patients presenting with recurrent symptoms attributed to the chronic ICVA occlusion. We searched previous literature using PubMed databases during the same period as comparison. ResultsEleven patients out of 14 presented initial symptoms to intervention less than 90days. The occlusion course was extrapolated on simultaneous two-vessel injection angiography or high-resolution MR imaging (HRMRI) in 13 cases. Nine patients had the occlusion beyond the origin of posterior inferior cerebellar artery (PICA) and 5 had the occlusion proximal to the PICA origin. The technical success rate of recanalization was 85.7% (12/14). Two patients (14.3%, 2/14) had peri-procedural complications: 1 developed TIA and 1 presented with perforator occlusion syndrome. Using the keyword-based search, we identified 6 studies at the same period. A total of 34 patients underwent recanalization with the successful recanalization rate at 94.1%, peri-procedural complication rate at 17.6% and mortality at 2.9%, respectively. ConclusionOur single-center study illustrated the feasibility and safety of ICVA recanalization. Great care should be taken as revascularization is of high risk. When patient selection, occlusion course and stage as well as neuroimaging evaluation are considered, endovascular recanalization may be a useful therapeutic modality.

Recent advances in the management of symptomatic vertebral artery stenosis.

Vertebrobasilar stenosis accounts for 20% of posterior circulation strokes and is associated with high risk of early stroke recurrence. We review data from randomized controlled trials examining whether stenting may reduce this risk, including the recently published Vertebral Artery Ischaemia Stenting Trial (VIST). VIST and VAST (Vertebral Artery Stenting Trial), having recruited both intracranial and extracranial vertebral stenosis and showed a low rate of perioperative stroke for extracranial (0 and 2%, respectively), but a higher rate for intracranial stenosis (15 and 22%, respectively). In VIST, the primary endpoint of stroke occurred in five patients in the stent group vs. 12 in the medical group (hazard ratio 0.40; 95% confidence interval 0.14-1.13, P = 0.08), although when days from last symptoms were adjusted for, the hazard ratio was 0.34 (95% confidence interval 0.12-0.98; P = 0.046). SAMMPRIS (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis) recruited only intracranial vertebral stenosis and showed a better outcome with intensive medical therapy than stenting. Stenting of extracranial stenosis can be performed with a low operative risk. VIST suggests it may reduce longer term stroke risk, but this needs confirming in larger trials. For intracranial stenosis, due to a higher operative risk, current evidence favours medical treatment. SAMMPRIS have emphasized the need for intensive medical therapy whether or not stenting is performed.

Balloon-expandable stent angioplasty in the treatment of vertebral artery stenosis in the V2 segment.

IntroductionVertebral artery stenosis is a major cause of posterior circulation ischemia in the elderly. There is not a clear consensus on the optimal therapeutic approach for symptomatic extracranial vertebral artery stenosis.AimTo evaluate the feasibility and efficacy of balloon-expandable stent angioplasty in the treatment of vertebral artery stenosis in the V2 segment.Material and methodsFive patients with vertebral artery stenosis (V2 segment) and treatment of percutaneous transluminal stenting from July 2009 to June 2014 were retrospectively evaluated. All patients underwent color Doppler, transcranial color Doppler (TCD), CT angiography (CTA) and cerebral digital subtraction angiography (DSA) preoperatively. Whether there was osseous oppression was determined according to neck computed tomography (CT) and CTA. After the surgery, angiography was performed to determine if there was infarction or bleeding in the intracranial vertebral artery, basilar artery and posterior cerebral artery. The surgical parameters, residual stenosis, complications, etc. were recorded and evaluated. The patients were followed up accordingly.ResultsFive patients (3 males, 2 females; average age of 66 ±4.2, range of 54–75) were enrolled in the study. Balloon-expandable stents were successfully implanted in the 5 patients. The mean residual stenosis after the balloon-expandable stenting (preoperative: average, 87.0 ±6.6%, range: 75–93%) was 12.6 ±7.8% (range: 5–25%). The clinical symptoms disappeared or receded. No serious complications occurred.ConclusionsThe balloon-expandable stent angioplasty seemed to be feasible and efficacious in treating vertebral artery stenosis in the V2 segment. Further study with a large sample size is needed.

Angioplasty and drug-eluting stent for vertebral artery stenosis

Objective To study the efficacy, safety, and feasibility of angioplasty and drug-eluting stents (DESs) in the treatment of vertebral artery stenosis. Patients and methods The study was carried out on 20 patients (17 patients with vertebral artery endovascular stenting and three patients with angioplasty alone). The success rate, perioperative complications, and long-term effectiveness were evaluated. Results A total of 17 DESs were implanted and three patients with angioplasty alone. The success rate was 100%. The degree of stenosis decreased from 78.25±10.17 to 11.50±7.45% (P Conclusion Angioplasty and DESs is a safe and effective strategy for the treatment of symptomatic vertebral artery stenosis.

Spotlight on the September 19 issue

#### Notable in Neurology This issue features an article that compares the risks and benefits of vertebral angioplasty and stenting with best medical treatment alone for symptomatic vertebral artery stenosis and another that suggests neuropsychological assessment, T1-weighted MRI, and diffusion tensor imaging might help identify early biomarkers in the presymptomatic stage of frontotemporal dementia and amyotrophic lateral sclerosis. A featured Views & Reviews examines causal claims of medication overuse headache for patients with …

Stenting for symptomatic vertebral artery stenosis: The Vertebral Artery Ischaemia Stenting Trial.

Objective:To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis.Methods:VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant.Results:Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05).Conclusions:Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk.ISRCTN.com identifier:ISRCTN95212240.Classification of evidence:This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.

Simultaneous vertebral and subclavian artery stenting.

IntroductionVertebrobasilar territory ischemia leads to disabling neurological symptoms and may be caused both by vertebral artery (VA) and subclavian artery (SA) stenosis. The coexisting symptomatic ipsilateral VA and proximal SA stenosis should be considered as a true bifurcation lesion for percutaneous treatment.AimTo evaluate the safety and efficacy of simultaneous angioplasty of vertebral and subclavian stenosis.Material and methodsFifteen patients (age 69.5 years, 46.7% men, all symptomatic from posterior circulation (history of stroke, transient ischemic attack, chronic ischemia symptoms)) were scheduled for simultaneous SA/VA angioplasty. Clinical and duplex ultrasound follow-up was conducted 1, 6 and 12 months after the procedure.ResultsThe technical success rate was 100%. Single balloon-mounted stent angioplasty was performed for all VAs and for 13 (86.7%) SAs. In 4 cases a simultaneous radial and femoral approach was required. The mean North American Symptomatic Carotid Endarterectomy Trial (NASCET) VA stenosis was reduced from 88.7 ±9.7% to 5.7 ±6.8% and SA stenosis from 80 ±12.2% to 11 ±12.3% (p < 0.01). No periprocedural death, stroke, myocardial infarction or transient ischemic attack occurred. During follow-up (range: 6–107 months) in 10 of 15 (66.7%) patients relief of chronic ischemic symptoms was observed. No stroke/TIA occurred. One cardiovascular and 2 non-cardiovascular deaths were recorded. There was 1 symptomatic vertebral and 1 subclavian in-stent restenosis, and 2 cases of asymptomatic VA in-stent occlusion occurred.ConclusionsSimultaneous vertebral and subclavian artery stenting is safe and effective. The restenosis rate remains at an acceptable level and it may be treated successfully with drug-eluting balloon angioplasty. In selected patients a dual radial and femoral approach may facilitate the procedure.

Endovascular vs. medical therapy in symptomatic vertebral artery stenosis: a meta-analysis.

This meta-analysis aims to compare percutaneous transluminal angioplasty (PTA) to medical treatment (MT) for symptomatic vertebral artery stenosis (SVAS) treatment. We searched PubMed, Springer, Google Scholar, Clinical Trials, Cochrane Central, Chinese National Knowledge Infrastructure, and China Biological Medicine databases. All relevant comparative trials were included. All summary estimates were calculated by random-effect models. Ten comparative trials involving 672 patients were identified. Within 30-day follow-up, there was no significant difference between PTA plus MT and MT alone in vascular death, any stroke, posterior circulation TIA, posterior circulation infarction, and ischemic stroke (all P>0.05). With a follow-up of more than 1year, no significant difference was found between PTA plus MT and MT alone in all-cause death (3 vs. 7%, P=0.24), vascular death (4 vs. 7%, P=0.34), posterior circulation stroke (5 vs. 8%, P=0.48), posterior circulation ischemic events (8 vs. 25%, P=0.23), posterior circulation TIA (10 vs. 38%, P=0.11), posterior circulation infarction (6 vs. 12%, P=0.51), vertebral artery occlusion (6 vs. 12%, P=0.58), and in secondary long-term events, including any stroke, anterior circulation stroke, hemorrhagic stroke, and myocardial infarction (all P>0.05), although PTA plus MT could largely reduce the vertebral artery stenosis rate [MD 63.05%, 95% CI (32.77-93.34%), P<0.01]. Hence, PTA plus MT may be not superior to MT alone for SVAS treatment. Larger randomized trials are needed to verify the optimum therapy for SVAS.

Cerebellar cortical infarct cavities and vertebral artery disease.

Cerebellar cortical infarct cavities are a newly recognised entity associated with atherothromboembolic cerebrovascular disease and worse physical functioning. We aimed to investigate the relationship of cerebellar cortical infarct cavities with symptomatic vertebrobasilar ischaemia and with vascular risk factors. We evaluated the MR images of 46 patients with a recent vertebrobasilar TIA or stroke and a symptomatic vertebral artery stenosis ≥50% from the Vertebral Artery Stenting Trial (VAST) for the presence of cerebellar cortical infarct cavities ≤1.5cm. At inclusion in VAST, data were obtained on age, sex, history of vertebrobasilar TIA or stroke, and vascular risk factors. Adjusted risk ratios were calculated with Poisson regression analyses for the relation between cerebellar cortical infarct cavities and vascular risk factors. Sixteen out of 46 (35%) patients showed cerebellar cortical infarct cavities on the initial MRI, and only one of these 16 patients was known with a previous vertebrobasilar TIA or stroke. In patients with symptomatic vertebrobasilar ischaemia, risk factor profiles of patients with cerebellar cortical infarct cavities were not different from patients without these cavities. Cerebellar cortical infarct cavities are seen on MRI in as much as one third of patients with recently symptomatic vertebral artery stenosis. Since patients usually have no prior history of vertebrobasilar TIA or stroke, cerebellar cortical infarct cavities should be added to the spectrum of common incidental brain infarcts visible on routine MRI.

Symptomatic bilateral extra-cranial vertebral artery dissections induced by sexual activity

Introduction: Trauma is a well-recognized cause of vertebral artery dissection (VAD) and even minor episodes of trauma, including sneezing and vigorous exercise, have been implicated. Symptomatic bilateral vertebral artery dissections after sexual activity to our knowledge has not been reported. Case r eport: A 32-year-old female presented with a three week history of occipito-cervical headaches. Noninvasive imaging identified bilateral vertebral artery dissections. The etiology was inferred after a directed clinical history revealed sexual activity characterized by aggressive repeated neck hyperextension from hair-pulling during intercourse. Conclusion: We report a case of symptomatic bilateral VAD in the setting sexual intercourse related trauma. The quality of clinical data gathering, in particular pertinent history taking is imperative in determining a potential cause. This is important in patient counselling so as to prevent recurrence.