Vertebral Occlusion Research Articles

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.

Feasibility and safety of direct catheter-based thrombectomy in the treatment of acute ischaemic stroke. Cooperation among cardiologists, neurologists and radiologists. Prospective registry PRAGUE-16.

The aim of this study was to evaluate the role of direct catheter-based thrombectomy (d-CBT, without thrombolysis) and the feasibility and safety of d-CBT performed in an interventional cardiology centre. This single-centre, prospective observational registry based on the pre-specified protocol included three months of follow-up. The decision to perform acute stroke intervention was made by a neurologist based on the clinical and imaging findings. Inclusion criteria were moderate-to-severe acute ischaemic stroke (NIHSS ≥6), <6 hours from symptom onset, no large ischaemia on the admission CT scan and CT evidence for an occluded large artery. The primary outcome was functional neurologic recovery (mRS 0-2) at three months. Key secondary outcomes were the angiographic recanalisation rate and symptomatic intracranial bleeding. A total of 115 consecutive patients (mean age 66 years) were enrolled during a period of four years: 84 patients underwent d-CBT and 31 patients bridging thrombolysis with immediate catheter intervention (TL-CBT). The annual number of procedures increased from 13 (initial 12 months) to 41 (last 12 months). Angiographic success (TICI flow 2b-3) was 69% after d-CBT and 81% after TL-CBT. It was higher in isolated occlusions of the middle cerebral artery (MCA, 74% and 100%) or of the proximal internal carotid artery (ICA, 80% and 100%), while it was lower in combined ICA+MCA occlusions (63% and 70%) and in basilar or vertebral occlusions (57% and 50%). Neurologic recovery (mRS ≤2 after 90 days) was achieved in 40% of patients. It was higher (43%) in anterior circulation strokes than in posterior circulation strokes (25%). Direct CBT led to neurologic recovery in 36%, while in TL-CBT this was 52%. Best clinical outcomes (51% and 71% neurologic recovery rates) were achieved among patients with isolated MCA occlusion. Any symptomatic intracranial bleeding was present in 3.6% (d-CBT) and 6.5% (TL-CBT). Vessel perforation or major dissection occurred in 5.2% overall, and distal embolisation to other territory in 3.5% of patients. Direct catheter-based thrombectomy may be considered in patients with contraindications for thrombolysis or in patients with very short CT-groin puncture times. A randomised trial is needed to evaluate better the role of direct catheter-based thrombectomy. Acute stroke interventions performed in close cooperation among cardiologists, neurologists and radiologists are feasible and safe.

Abstract WP144: Ultrasound Criteria for Assessment of Vertebral Artery Origins

Introduction: We sought to validate ultrasound as a reliable means of assessing vessel stenosis of vertebral artery origins. Methods: We reviewed 1135 patient charts with ultrasound of the posterior circulation performed 2008-2015 in our Neurovascular Laboratory Imaging Institute. Inclusion criteria consisted of ultrasound and digital subtraction angiography (DSA) performed within three months as well as absence of prior stent placement, resulting in 218 vessels in 133 patients. Using DSA as the gold standard, we determined sensitivity and specificity of ultrasound in detecting occlusion at vertebral artery origin. All patients with non-occluded vertebral artery origins without stent were evaluated for degree of stenosis on DSA, and compared to mean flow velocity (MFV) on ultrasound. Results: Among 218 vertebral artery origins evaluated, ultrasound showed sensitivity of 85.7% (95% confidence interval (CI) 69.7-95.2%) for occlusion and specificity of 99. 5% (95%CI 96.9-99.9%). Among 126 arteries without occlusion, &lt;50% stenosis had average MFV 39.5 cm/s (SD 19.9), 50-69% stenosis had average MFV 69.2 cm/s (SD 34.7), and severe 70-99% stenosis had average MFV 129 cm/s (SD 30.65), p&lt;0.001 by Kruskal-Wallis test. For detecting ≥70% stenosis, c-statistic of ROC curve was 0.81, and MFV of 70 cm/s has 82% sensitivity and 88% specificity of ≥70% stenosis. Conclusion: Ultrasound has good sensitivity and excellent specificity for detecting vertebral origin occlusion. Flow velocity can be used to screen for severe stenosis of vertebral artery at origin.

Evaluation of symptomatic vertebral occlusions using CT angiography and color duplex sonography

Evaluation of symptomatic vertebral occlusions using CT angiography and color duplex sonography

Acute vertebral artery origin occlusion as “a blind spot”

Keywords: angioplasty with stenting; artery-to-artery embolism; occlusion; tissue-plasminogen activator; vertebral artery origin

Anterior spinal artery as a collateral pathway in a case of unilateral vertebrobasilar occlusion: A case report and literature review

Background: Vertebral artery (VA) occlusion is an important cause of stroke in the posterior circulation along with basilar artery occlusion. Intracranial VA disease accounts for 21% of patients with posterior circulation stroke and is bilateral in nearly half of them. Anterior Spinal Artery (ASA) originating from cervical VA to intracranial distal VA and Basilar artery is a possible and infrequent source of collaterals. Case description: We report a case of acute unilateral vertebral artery occlusion with retrograde flow from ASA as the only collateral pathway reconstituting distal circulation. Conclusion: Anterior Spinal Artery can play an important role in the setting of unilateral or bilateral vertebral occlusion. Retrograde flow through ASA could reconstitute distal circulation. Adequacy of flow and neurological improvement in this situation depends on the presence of other collateral channels, other vertebral artery and on patency of vertebrobasilar junction.

Manifestations of stroke

The book is divided into two parts namely “Neurologic and Other Disorders” and “Topographic Syndromes”. The first section begins with the motor syndromes, the most common stroke clinical syndrome. The authors have elaborated the various motor manifestations in a simple way. The stroke sensory syndromes are dealt with in a concise manner. The chapter on eye movement abnormalities is very informative. However, inclusion of a few images showing the neuroanatomical pathway would have made it easy to understand. The chapter on visual dysfunctions deals with the visual symptoms in relation to the optic nerve pathway and also covers various visual phenomena. One of the important aspects of stroke clinical diagnosis is differentiating between anterior and posterior circulation strokes. The chapter on dizziness and vertigo explains the clinical clues in localising posterior circulation strokes in relation to the presence of dizziness and vertigo. The chapter “Impaired Consciousness”, covers the various types of disturbances in consciousness. Also, the coma like states which are important in the prediction of prognosis in stroke patients have been discussed. The chapter on language disorders in stroke is very simple and easy to understand. The common language dysfunctions in stroke are discussed well. The section on memory dysfunction is short and crisp. One of the intriguing aspects of stroke is right hemisphere syndromes. Although the symptomatologies of right hemisphere stroke have been enumerated, this section could have been organized better to improve readability. Vascular cognitive impairment (VCI) is an important post-stroke disability. Post-stroke dementia and cognitive impairment are covered well including the various criteria used for the diagnosis of VCI. One of the neglected disabilities is anxiety and depression after stroke. The chapter on mood disorders contains the risk factors for anxiety and depression after stroke. In addition, the authors have elaborated on the diagnosis and treatment of these conditions. Stroke disconnection syndromes such as apraxia, agnosia, etc, are described in detail. The common disconnection syndromes are also explained well. Autonomic dysfunctions in stroke are commonly seen. The salient autonomic syndromes that occur following stroke are highlighted along with explanation on the neuroanatomical correlates. Another common speech disorder which occurs in stroke is dysarthria/mutism which can vary according to the site of the lesion and this section also is well covered. The pathophysiology, diagnosis and treatment of post-stroke dysphagia are discussed in a comprehensive manner including the various tools used to evaluate dysphagia. Certain strokes can present with breathing difficulties. The physiology, pathophysiology and clinical syndromes of ventilatory disorders are dealt with methodically. The chapter on lacunar strokes describes the different types of lacunar syndromes and also focus on the pathogenesis and outcome in these patients. The second section of the book begins with a lucid chapter on arterial territories of the brain. Brain maps of various territories in the cerebrum, brainstem and cerebellum are included. The territories depict the neuroimaging sections in clinical practice. This section lays down the foundation for the remaining chapters of the book. All the chapters begin with basic anatomy, aetiology and then elaborate the clinical features. The chapters on thalamic, caudate and putaminal infarcts/haemorrhages are very informative. The pathophysiology of lobar haemorrhage including the mechanisms of raised intracranial tension is explained clearly. The chapter on subarachnoid and intraventricular haemorrhage gives an overview of the two important conditions. The large hemispheric infarction deals with the current concepts in pathophysiology and also about the recent surgical trials. There is some degree of repetition in the chapters on midbrain, pontine and medullary strokes. The presentations, aetiologies and prognosis of cerebellar strokes are appropriate. The strokes in the territories of vertebral, basilar and carotid arterial occlusions are described very well. Finally, the last last two chapters also discuss venous ischaemic and spinal cord syndromes. In the era of modern technology where less importance is given for bedside skills, this book will be a great asset to neurology residents, neurologists and stroke neurologists/physicians.

Delayed intravenous thrombolysis based on MRI mismatch in posterior circulation stroke

The current time-based approach for patient selection for intravenous (IV) thrombolysis in an acute stroke setting neglects the individual variation of cerebral blood flow impairment. This approach restricts the eligible patient population. In the last decade, advanced imaging and especially MRI diffusion- and perfusion-weighted imaging (DWI-PWI) techniques have been used to select patients for IV thrombolysis outside the current 4.5 h time window. Most of these studies focus on the anterior (carotid artery) cerebral circulation only. We report the case of an acute ischemic stroke due to a dissection of the right vertebral artery and occlusion of the posterior inferior cerebellar artery with good clinical outcome. The patient received IV thrombolysis far beyond the current established time window. This decision was based upon a marked MRI DWI-PWI mismatch zone in the posterior circulation territory.

Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion.

Purpose. The outcome of recanalization in patients with chronic symptomatic intracranial vertebral artery (ICVA) total occlusion is poor. This paper reports the technical feasibility and long-term outcome of ICVA stenting in patients with chronic symptomatic total occlusion. Methods. Retrospective review of our prospectively maintained intracranial intervention database to identify patients with symptomatic total occlusion of ICVA with revascularization attempted >1 month after index ischemic event. Results. Eight patients (mean age 58 years) were identified. One had stroke and 7 had recurrent transient ischemic attacks. Four had bilateral ICVA total occlusion and 4 had unilateral ICVA total occlusion with severe stenosis contralaterally. Seven of 8 patients underwent endovascular recanalization, which was achieved in 6. Periprocedural complications included cerebellum hemorrhage, arterial dissection, perforation, and subacute in-stent thrombosis which occurred in 3 patients. One patient died of cerebellum hemorrhage. The other patients improved clinically after endovascular therapy. Conclusions. Stent-supported recanalization of ICVA total occlusion is technically feasible, and may become a viable treatment option in selected patients.

Recanalization of Symptomatic Vertebral Ostial Occlusion in Patients with Acute or Subacute Stroke

Vertebral artery recanalization in symptomatic stenosis/occlusion remains controversial, as no definite evidence exists regarding this topic. There are only a few reports regarding the feasibility and safety of recanalization in the first segment of the vertebral artery with atherosclerotic vertebral ostial occlusion. We report our experience treating first segment occlusion in 8 patients and present a balloon protection technique used to reduce the thromboembolic burden during the stent placement procedure. The outcome at 3 months showed an mRS ≤2 except for a patient with a poor initial status with basilar artery occlusion. Revascularization of a rather long first segment occlusion is technically feasible and can be safely performed by use of embolic protection methods.

Endovascular reconstruction of vertebral artery occlusion prior to basilar thrombectomy in a series of six patients presenting with acute symptomatic basilar thrombosis

Introduction and purposeSymptomatic acute basilar thrombosis is associated with a high mortality rate. Aggressive endovascular management has led to survival rates of 35–50%. We report the largest series of endovascular...

Bilateral mechanical rotational vertebral artery occlusion

Rotational vertebral artery occlusion, or bow hunter's stroke, is reversible, positional symptomatic vertebrobasilar ischemia. The typical mechanism of action is obstruction of a dominant vertebral artery with contralateral head rotation in the setting of baseline ipsilateral vertebral artery stenosis or occlusion. Here we present a rare case of mechanical occlusion of bilateral patent vertebral arteries manifesting as near syncope with rightward head rotation. Diagnostic cerebral angiography showed dynamic right C5 vertebral occlusion and left C2 vertebral occlusion. The patient underwent right C4/5 transverse process decompression. Postoperative angiogram showed patent flow through the right vertebral artery in neutral position and with head turn with resultant resolution of symptoms.

Acute Vertebral Artery Origin Occlusion Leading to Basilar Artery Thrombosis Successfully Treated by Angioplasty with Stenting and Intracranial Fibrinolysis

There are few reports describing stroke due to the acute occlusion of the vertebral artery (VA) origin successfully treated by endovascularily. The authors report a case of 78-year-old man suffering from stroke owing to acute VA origin occlusion associated with contralateral hypoplastic VA leading to basilar artery (BA) thrombosis. Cerebral angiography demonstrated that the right VA was occluded at its origin, the left VA was hypoplastic, and BA was filled with thrombus. The occlusion of VA origin was initially passed through with a microcatheter and microwire. Hereafter, angioplasty was performed followed by stenting with a coronary stent. The VA origin was successfully recanalized. Next, a microcatheter was navigated intracranially through the stent and fibrinolysis was performed for BA thrombus. The patient's symptoms gradually improved postoperatively. Stroke due to acute VA origin occlusion leading to BA thrombosis was successfully treated by angioplasty and stenting followed by intracranial fibrinolysis.

対側椎骨動脈（VA）閉塞をきたしている右椎骨動脈巨大動脈瘤（VGA）の1例

対側椎骨動脈（VA）閉塞をきたしている右椎骨動脈巨大動脈瘤（VGA）の1例

Neuroprotective and antioxidant potential of terpenoid fraction from Hygrophila auriculata against transient global cerebral ischemia in rats

Context: The plant Hygrophila auriculata (K. Schum) Heine. (Acanthaceae) is widely used in the Indian System of Medicine as “Rasayana” for treating brain and liver diseases.Objectives: The present study evaluated the in vivo antioxidant and neuroprotective effect of aterpenoid rich fraction (TF) from Hygrophila auriculata in a rat model of transient global cerebral ischemia (tGCI).Materials and methods: Male Wistar rats were grouped as sham control, tGCI control, vitamin E (500 mg/kg) and TF (100 & 200 mg/kg) treated groups. Following 7 days of drug administration, animals were subjected to tGCI by permanent occlusion of both vertebral and transient occlusion of carotid arteries for 10 min followed by reperfusion. The neuroprotective effect was assessed by tGCI induced neurological, sensory motor deficit in rats. Brain antioxidants such as superoxide dismutase (SOD), catalase (CAT) and malondialdehyde (MDA) were investigated. Further, a histopathological examination was done in CA1 hippocampus.Results: tGCI induction resulted in an increase in beam balance score (5.1), number of entries in open field (131) and a decrease in time spent in rotorod (47 s). In contrast, TF treatment resulted in a significant decrease in (p < 0.01) beam balance score (2.9), number of entries (67) and increased time spent in rotorod (63.25 s). There was also a significant (p < 0.001) decrease in brain SOD and GSH with an increase in MDA. TF treatment resulted in restoration of antioxidants and protection of hippocampal CA1 neurons against tGCI insult.Conclusion: It is concluded that TF from Hygrophila auriculata shows neuroprotective potential against tGCI induced oxidative stress.

Characteristics of vascular lesions in patients with posterior circulation infarction according to age and region of infarct.

Patients with posterior circulation infarction underwent CT angiography and magnetic resonance angiography. Intracranial and extracranial vasculopathy was evaluated according to age group and location of stroke. Patients aged > 60 years and < 60 years had similar rates of vertebral artery dominance and vertebrobasilar artery developmental or origin anomalies. Vertebrobasilar artery stenosis or occlusion and tortuosity occurred more frequently in patients aged > 60 years than < 60 years. The rates of vertebrobasilar artery anomalies and tortuosity were high in patients with posterior circulation infarction. Vertebrobasilar artery tortuosity occurred more frequently in patients aged > 60 years, whereas vertebrobasilar artery developmental anomalies occurred with similar frequency in patients aged < 60 years and > 60 years. Patients with infarction of the brainstem or cerebellum were more likely to have vertebral artery stenosis or occlusion, basilar artery stenosis or occlusion, vertebral artery dominance or tortuosity, and basilar artery tortuosity, and patients with infarction of the thalamus, medial temporal, or occipital lobes were more likely to have stenosis or occlusion of the vertebral or basilar arteries. Vertebrobasilar artery tortuosity, vertebral artery dominance (hypoplasia), and congenital variations of the vertebrobasilar system may lead to posterior circulation infarction at different locations in different age groups.

Recurrent Stroke as a Presenting Symptom of HIV-Associated Moyamoya Syndrome: Case Report (P05.242)

Objective: To report a case of a recurrent stroke as a presenting symptom of a newly diagnosed HIV-associated MMS. Background There is increasing evidence that HIV infection is a risk factor of stroke. Moyamoya syndrome (MMS) is a progressive vasculopathy affecting the circle of Willis with collateral development. There are only four case reports of HIV associated MMS stroke. However, no recurrent strokes caused by newly diagnosed HIV associated MMS has been previously reported. Design/Methods: Case report. Results: A 35 year old African American male with past medical history of stroke and vertebral artery occlusion presented with acute onset of left facial droop, left hemiparesis and hemisensory loss, left sided neglect and right gaze preference. MRI showed a large right MCA territory infarct and MRA showed age indeterminant right vertebral artery occlusion at the origin, and right MCA occlusion. Subsequent cerebral angiogram revealed right MCA long segment stenosis with increased lenticulostriate proliferation consistent with early stages of MMS. On admission, his platelets count was 45, and thrombocytopenia evaluation revealed HIV (ELISA and WB positive,CD4+ count-137 and viral load -161,674). Further studies including CSF, echocardiogram, lipid panel, HgA1c, hypercoagulable and vasculitis workup were unremarkable. It is most likely that his previous stroke and vertebral artery stump occlusion was due to HIV vasculopathy. Conclusions: Recurrent stroke due to MMS could be the first presenting symptom of HIV. This case report underlines importance of Brain Attack Coalition recent revision recommending HIV testing for all stroke patients admitted to the Primary Stroke Centers. Disclosure: Dr. Alqadi has nothing to disclose. Dr. Nadareishvili has nothing to disclose. Dr. Jadhav has nothing to disclose. Dr. Burger has nothing to disclose. Dr. Khaldi has nothing to disclose. Dr. Feinberg has nothing to disclose.

Small Posterior Fossa Strokes Causing Severe Vertigo - Clinical Signs and Anatomic Distribution of the "Lacunar" Acute Vestibular Syndrome (P02.249)

Objective: Describe the frequency, anatomic distribution, and clinical manifestations of small posterior fossa strokes in patients with acute vestibular syndrome (AVS). Background Small brainstem and cerebellar strokes affecting central vestibular pathways present clinically with AVS. Careful study of acute sub-centimeter lesion locations may help elucidate structure-function relationships. Design/Methods: Prospective case series (1999-2011). Consecutive AVS patients (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with ≥1 stroke risk factor underwent structured bedside examination and neuroimaging (almost all by MRI). Repeat imaging was obtained in patients with normal imaging but clinical signs suggestive of a central lesion. We identified those with strokes Results: Of 160 high-risk AVS presentations, 95 were caused by stroke. Of these, 16% (n=15/95) had sub-centimeter lesions. Lesions were located in the lateral medulla (9); peri-ventricular inferior cerebellar peduncle (2); ponto-medullary junction (1); lateral pons/8 th nerve root entry zone (1); nodulus (1); and midbrain tegmentum (1). False negative initial MRIs were present in 9% of the total (n=14/160) and 60% in this small stroke group (n=9/15). In all cases, the oculomotor “HINTS” exam (Head Impulse test of vestibular function, Nystagmus, and Test of Skew) suggested a central localization, eventually confirmed by imaging. Head impulse testing was abnormal (“mistakenly” suggesting a peripheral lesion) in two pontine cases. Non-oculomotor neurologic signs were present in only 33% (n=5/15) at initial presentation. Non-lacunar mechanisms were responsible in at least 7 cases (3 vertebral dissection, 3 vertebral occlusion, 1 cardiac emboli ). Conclusions: Small strokes in anatomic loci with direct vestibular connections produce AVS. Most are lateral medullary, but only a minority present with classic findings of Wallenberg syndrome. Oculomotor exam identifies these patients with greater accuracy than early MRI with DWI. Non-lacunar mechanisms are not infrequently the cause, suggesting greater risk than might be assumed for patients with such small infarctions. Disclosure: Dr. Kattah has received personal compensation for activities with Biogen Idec as a consultant. Dr. Kattah has received personal compensation in an editorial capacity for Bayer Pharmaceuticals Corporation. Dr. Pula has received personal compensation for activities with Bayer, Teva, Lundbeck, and Novartis as a speaker. Dr. Nair has nothing to disclose. Dr. Ying has nothing to disclose. Dr. Newman-Toker has nothing to disclose.

Bow hunter's syndrome with spontaneous improvement

A 74-year-old man complained of near loss of consciousness when he rotated his head to the left side. The symptom was reversed by returning his head to a neutral position. Transcranial Doppler studies with the patient's neck rotated into the left side revealed reduction of flow in his left vertebral artery. Vertebral angiography revealed a hypoplastic right vertebral artery and occlusion of the left vertebral artery at the C6 level on head rotation. We diagnosed him bow hunter's syndrome and treated him conservatively. Six months later, he was symptom-free on head rotation. Transcranial Doppler and vertebral angiography demonstrated the disappearance of the vertebral artery occlusion at the neck rotation. Some patient without any definite cause can be treated conservatively, and surgical interventions for bow hunter's syndrome should be carefully decided.

Pearls &amp; Oy-sters: A distinctive watershed area in the vertebrobasilar territory

The middle cerebellar peduncles may represent a distinctive watershed area in the vertebrobasilar circulation between the anterior inferior and superior cerebellar arteries. A 78-year-old man experienced 2 short-lasting episodes of vertigo with unstable gait during the 5 days before admission. One week previously, he had carried large fiberboard panels, involving sustained rotation of the neck in both directions. His past medical history included arterial hypertension and dyslipidemia. The initial general and neurologic examination was normal except for high blood pressure (194/109 mm Hg). Over the next few days, the patient developed rapidly worsening bilateral dysmetria and dysdiadochokinesia, more marked on the left, cerebellar dysarthria, and unstable stance and gait. Cerebral CT showed leukoaraiosis and lacunar sequelae of both corona radiata and of the left thalamus and caudate nucleus. CT arteriography showed narrowing and irregularities of the V2 segment of the left vertebral artery and occlusion of its V3 segment. Ultrasonography and Doppler examination confirmed the stenosis of the left V2 segment and occlusion of the left V4 segment. There was also an 80% stenosis in the V2 segment of the right vertebral artery. Cerebral MRI showed symmetric acute ischemia of both middle cerebellar peduncles (MCPs) and of the deep right cerebellar hemisphere (figure, A). Fat saturation sequences showed a wall hematoma …