Vertebrobasilar Insufficiency Research Articles

Comprehensive evaluation of the mechanism of Banxia Baizhu Tianma Decoction in ameliorating posterior circulation ischemia vertigo based on integrating fecal short-chain fatty acids and 16S rRNA sequencing

Posterior circulation ischemia vertigo (PCIV) is vertebrobasilar insufficiency resulting in vertigo. Banxia Baizhu Tianma Decoction (BBTD) is broadly applied to treat PCIV in China, but its efficacy and detailed mechanism remains unclear. Therefore, this study aims to investigate the effects of BBTD on PCIV, and identify important gut microbiota and its derived short-chain fatty acid (SCFA) changes and the detailed mechanism through 16 S rRNA sequencing with SCFAs profiling. In this study, the model of PCIV was established by surgical ligation of the right subclavian artery (RSCA) and right common carotid artery (RCCA). We found that BBTD administration effectively reduced the volume of cerebral infarction and improved neurologic functions, reduced neuronal apoptosis and neuroinflammatory. Moreover, BBTD significantly modulated the diversity and composition of the gut microbiota, including increasing the relative abundance of Lactobacillus, Prevotella and Akkermansia and decreasing relative abundances of Lachnospiraceae, Bacteroidetes (S24–7) and Ruminococcaceae. BBTD treatment also increased propionate content. Propionate mediates the the recovery of neurological functions and anti-apoptotic effects of BBTD in PCIV rat. Our findings wish to discover the potential mechanism of BBTD treatment on PCIV and promote its clinical application.

Dynamic vertebral artery occlusion aka bow hunter syndrome causing posterior fossa stroke in a young adult: a case report

BackgroundBow Hunter syndrome (BHS) is a rare, but important cause of posterior circulation stroke. It is also known as Rotational vertebral artery syndrome and is caused by transient dynamic vertebro-basilar insufficiency on movement of the neck in the presence of certain soft tissue or bone anomalies in the cranio-vertebral region.Case presentationWe present a case of Bow hunter syndrome in an 18-year-old adult male who presented with vomiting, occipital headache and loss of balance, with findings of posterior circulation stroke on imaging. Medical causes of young stroke, including vasculitis and clotting disorders were ruled out, following which a diagnostic conventional angiography and CT angiography was performed. The cause of vascular compromise in our case was the presence of vertebral anomalies, in particular, the presence of a partial ponticulus posticus with formation of an incomplete arcuate foramen. He was treated with cervical spine immobilisation and C1–C2 fixation. In addition, our patient had a single posterior inferior cerebellar artery (PICA) on the side of the dynamic insufficiency, which lead to bilateral cerebellar infarcts. Our case is unique because it demonstrates a combination of osseous and vascular developmental anomalies resulting in posterior circulation stroke.ConclusionsThough uncommon, BHS should be considered in the list of differentials in otherwise unexplained cases of posterior circulation stroke. Conventional angiography with dynamic manoeuvres is the modality of choice for documenting the rotational vertebral artery occlusion.

Kimmerle anomaly as a cause of vertebrobasillary insufficiency and vertebral pain syndrome

The Kimmerle anomaly is one of the varieties of craniovertebral junction anomalies. Currently, it is one of the main causes of vertebrobasilar insufficiency, vertebral pain and vegetative syndromes. Despite a sufficient number of publications on this problem, the Kimmerle anomaly still remains not fully understood. Insufficient awareness of primary care physicians about this pathology, a wide variety of clinical manifestations, the absence of pathognomonic neurological syndromes, the complexity of the analysis of imaging data cause difficulties in identifying this anomaly. The article describes the epidemiology, pathogenesis, and clinical picture of Kimmerle anomaly. Further, the paper presents modern methods of its diagnosis (spondylography, ultrasound, MRI, MSCT, etc.) and treatment. In conclusion, the authors present ways to optimize the diagnosis and treatment of Kimmerle anomaly.

Evaluation of the Relationship between Total Vertebral Artery Flow and Quality of Life in Patients with Vertebrobasilar Insufficiency

Background: Vertebrabasilar insufficiency is a common problem in the community and causes limitation in daily physical activities of patients. A questionnaire called the dizziness disability inventory is used to show the change in the quality of life of the patients. In our study, we wanted to show the change in quality of life indexes of patients with vertebrabasilar insufficiency depending on the degree of insufficiency. Material and metod: Dizziness disability inventory was filled in patients diagnosed with vertebrabasilar insufficiency by Doppler ultrasonography and the relationship between the degree of vertebrabasilar insufficiency and the results of the questionnaire was investigated. Results: A statistically significant difference was found between the groups according to the mean questionnaire results in patients classified as mild, moderate and severe according to their vertebrabasilar insufficiency. The mean questionnaire scores of those with severe vertebrabasilar impairment were significantly higher than those with moderate and mild impairment, but no significant difference was found between those with moderate and mild impairment. There was no significant difference in mean questionnaire scores between gender, treatment intake and duration of complaints. It was found that there was a significant decrease in total vertebral artery output depending on age. Conclusion: In patients with vertebrabasilar insufficiency, restriction in activities of daily living, deterioration in quality of life are observed. It should be noted that the decrease in the quality of life index of the patients will be higher according to the severity of the vertebrabasilar insufficiency

Complementary advantages of microsurgical treatment for vertebral artery dolicoarteriopathies: Mitigating symptoms of restless leg syndrome in refractory vertebrobasilar insufficiency

Objective: This retrospective study examines the impact of microsurgical treatment on vertebral artery (VA) dolicoarteriopathies and associated restless leg syndrome (RLS) in patients with refractory vertebrobasilar insufficiency (VBI). Patients and Methods: We analyzed 78 patients with grade 2 and 3 kinks, and found out that the targeted microsurgical interventions, primarily designed to address VBI, improved secondary RLS symptoms in 12 patients. Procedures included arteriolysis and, depending on severity, grafting. Statistical analysis was conducted using Stata 16 (StataCorp LP, Texas, USA). Results: In twelve patients aged 55 to 72 years with refractory VBI and drug-resistant RLS, micro-neurosurgical correction of V1 segment dolicoarteriopathy, abnormal elongation and kinks in the artery, demonstrated promising outcomes. Postoperatively, 83.33% (10 patients) reported complete resolution of RLS symptoms, and 16.66% (2 patients) experienced partial symptom relief (p

Secondary Benefits of Microsurgical Intervention on the Vertebral Artery (V1 Segment) for Refractory Vertebrobasilar Insufficiency: Alleviation of Parkinsonism-Like Symptoms

ObjectiveTo investigate the outcomes of micro-neurosurgical interventions on V1 segment of vertebral artery (VA) in patients with refractory vertebrobasilar insufficiency (VBI) due to dolicoarteriopathy and external compressions and to assess the secondary benefits of Parkinsonism-like symptoms. MethodsRetrospective analysis encompassed 101 patients treated for VA dolicoarteriopathy or compression-related refractory VBI from 2016-2023. Of these, 16 patients exhibited drug-resistant Parkinsonism-like symptoms. The diagnostic evaluation included cerebral CT/MR angiography or DSA and brain CT or MR perfusion studies, corroborated by preoperative and 6- and 12-month postoperative MDS-UPDRS Part 3 assessments. Data was analyzed through Turkey's 'E-nabız' system, employing Stata16 for statistical scrutiny. ResultsA significant reduction in MDS-UPDRS scores was observed (preoperative: 26.75 ± 10.91; 6 months: 23.09 ± 9.24; 12 months: 22.5 ± 8.73; P<0.001). Postoperative follow-up denoted that 43.7% of patients ceased medication, and 50% reduced antiparkinsonian drugs. The micro-neurosurgical approach resulted in complete remission of VBI-related symptoms in 84.6% of patients, with the rest showing partial or marked improvement. At six months post-operation, perfusion studies revealed posterior border zone or cerebellar perfusion enhancements in 81% (13 out of 16) of patients, with full symptom resolution, while the remaining 19% (3 out of 16) showed partial perfusion and clinical improvements, particularly in regions supplied by the posterior cerebellar artery (PCA) or posterior inferior cerebellar artery (PICA). The absence of operative mortality and minimal transient morbidities underscored the procedure's safety. ConclusionMicroneurosurgery for VA anomalies in refractory VBI patients, particularly those with concomitant parkinsonian-like syndromes, has demonstrated potential in symptom remission and medication reduction.

Endovascular Approach in Treating Vertebrobasilar Insufficiency: A Systematic Review.

Vertebrobasilar insufficiency (VBI) is a significant medical condition that results from a lack of adequate blood flow to the posterior circulation of the brain. The first-line treatment involves the use of antiplatelet therapy, but in cases where patients are not responsive to drug therapy, surgical management is the next viable option. In the past, open endarterectomy was the preferred surgical approach for treating critical VBI patients. However, due to its high mortality rates and severe peri-procedural complications, its usage has decreased. Instead, the endovascular approach has emerged as an alternative surgical option for resolving VBI. This review explores the current literature to assess the effectiveness of endovascular interventions in treating VBI patients. It also highlights potential complications and adverse effects associated with these treatments while identifying gaps in the current research that warrant further investigation. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to extensively search relevant literature on endovascular approaches for treating VBI patients on PubMed, BioMed Central, and ClinicalTrials.gov. The findings suggest that endovascular treatments have demonstrated significant technical success in treating VBI, with low mortality rates and minor adverse effects, such as intracranial hemorrhage and restenosis. The overall incidence of these complications is relatively low. Combining medical therapies with endovascular interventions has improved outcomes and reduced restenosis rates. However, there are methodological limitations and inconsistencies in the current literature that necessitate further investigation. Future research should focus on larger, randomized clinical trials and direct comparisons with other treatment options to obtain more conclusive evidence.

НЕРЕШЕННЫЕ ВОПРОСЫ ЛЕЧЕНИЯ ИШЕМИЙ ГОЛОВНОГО МОЗГА ПРИ ОККЛЮЗИОННО-СТЕНОТИЧЕСКОМ ПОРАЖЕНИИ ПОЗВОНОЧНЫХ АРТЕРИЙ

Background. The relevance of the review is determined by the fairly high incidence of strokes in the vertebrobasilar region. Aim. To analyze the literature on occlusive-stenotic lesions of the vertebral arteries as the causes of ischemic strokes and methods of their treatment. Results. It has been established that the problem of ischemic strokes due to occlusive-stenotic lesions of the vertebral arteries is a poorly covered topic. Existing options for eliminating stenosis of the vertebral artery mouth have advantages and disadvantages, and vary depending on many factors. Conclusions. The most effective method of treating occlusive-stenotic lesions of the vertebral arteries, which cause the development of vertebrobasilar insufficiency, has not yet been finally determined. This emphasizes the need for further research to develop a pathogenetically based treatment algorithm for such patients.

Diagnostic importance of phenotypic features of undifferentiated connective tissue dysplasia in spondylogenic vertebro-basilar insufficiency

Background: The circulatory insufficiency in the vertebrobasilar system is significantly influenced by the spondylogenic mechanism. To understand the degenerative-dystrophic changes in the cervical spine, an assessment of the connective tissue’s condition is required. The primary contributor to pathological conditions of connective tissue is undifferentiated connective tissue dysplasia (UCTD). Aim: To assess the predictive importance of constitutional-biological markers (CBM) of UCTD in patients with spondylogenic vertebro-basilar insufficiency. Materials and Methods: The research was carried out using the results of a comprehensive clinical and anamnestic examination of young patients with vertebrobasilar insufficiency. The study focused on investigating the main characteristics of CBM by comparing two groups of patients: one group with vertebrobasilar insufficiency (n = 136) and a control group without vertebrobasilar insufficiency (n = 136). The distribution of individual factors was analyzed using evidence-based medicine, modern clinical-statistical analysis methods such as variance and correlation analysis, as well as prognosis methods like serial analysis of Wald in modification of E.V Gubler to determine the diagnostic (I2, bit) and predictive value and impact factors of the different markers. Results: The most significant CBM for UCTD were found to be presence of structural imbalance, scoliosis or kyphosis of the cervical spine, flatfoot, and vision impairments. Conclusion: This study suggests that the diagnostic and prognostic value of CBM for UCTD is crucial in establishing a system of diagnostic and prognostic algorithms for evaluating the risk of developing vertebrobasilar insufficiency (SVBI).

Own experience in catheter angiography and interventional treatment of patients with probable vertebrobasilar insufficiency

The vertebrabasilar (VB) system plays an essential role in the circulation of main structures of nervous system. About 25% of ischemic brain strokes are located in the vertebrobasilar circulation. 20-25% of them are due to atherosclerosis, leading to formation of hemodynamically significant stenoses in both vertebral arteries. Catheter angiography proves and visualise with great accuracy vascular pathology along the course of the extracranial segments of cerebral arteries. Interventional treatment in patients with significant vertebral artery stenoses is an established and safe method of treatment, complementing optimal drug therapy, and preceding surgical treatment.

Gastrodin alleviates premature senescence of vascular endothelial cells by enhancing the Nrf2/HO-1 signalling pathway.

Endothelial dysfunction is an independent risk factor for stroke. The dysfunction of endothelial cells (EC) is closely concerned with EC senescence. Gastrodin (GAS) is an organic compound extracted from the dried root mass of the Orchidaceae plant Gastrodiae gastrodiae. It is used clinically to treat diseases such as vertebrobasilar insufficiency, vestibular neuronitis and vertigo. In the present study, we used hydrogen peroxide (H2 O2 )-induced human umbilical vein endothelial cells (HUVECs) to establish an invitro EC senescence model and to investigate the role and mechanism of GAS in EC senescence. It's found that H2 O2 -treated HUVECs increased the proportion of senescence-associated β-galactosidase (SA β-gal) positive cells and the relative protein expression levels of senescence-associated cyclin p16 and p21. In addition, GAS reduced the proportion of SA β-gal positive cells and the relative protein expression levels of p16 and p21, and increased the proliferation and migration ability of HUVECs. Meanwhile, GAS increased the expression of the anti-oxidative stress protein HO-1 and its nuclear expression level of Nrf2. The anti-senescence effect of GAS was blocked when HO-1 expression was inhibited by SnPPIX. Furthermore, absence of HO-1 abolished the effect of GAS on HUVEC proliferation and migration. In conclusion, GAS ameliorated H2 O2 -induced cellular senescence and enhanced cell proliferation and migration by enhancing Nrf2/HO-1 signalling in HUVECs. These findings of our study expanded the understanding of GAS pharmacology and suggested that GAS may offer a potential therapeutic agent for stroke.

THE STUDY OF ASSOCIATIONS BETWEEN IL1Β C3953T GENE POLYMORPHISM AND CLINICAL-NEUROLOGICAL, NEUROIMAGING, HEMODYNAMIC CHARACTERISTICS AND COGNITIVE DYSFUNCTION IN PATIENTS WITH POST-INFECTIOUS ENCEPHALOPATHY

The aim: To investigate potential associations between the C3953T polymorphic variant of the interleukin-one beta (IL1β) gene and clinical-neurological, neuroimaging, hemodynamic characteristics, as well as cognitive dysfunction in patients with post-infectious encephalopathy (PIE).&#x0D; Materials and methods: A total of 128 patients with post-infectious encephalopathy (PIE) who were receiving inpatient treatment in the neurological departments of the Communal Non-commercial Enterprise “Ternopil Regional Clinical Psychoneurological Hospital” of Ternopil Regional Council,” Ternopil, Ukraine, were examined and included in the retrospective analysis in 2021–2022. The molecular-genetic testing was performed for 26 patients in the molecular genetics laboratory of the State Institution “Reference Centre for Molecular Diagnostics of the Ministry of Health of Ukraine,” Kyiv. The control group consisted of 12 people, who were representative in age and gender. Statistical processing of the results was performed using the STATISTICA 10.0 software.&#x0D; Results: Analysis of the dependence of neuroimaging changes on the frequency of genotypes of the C3953T polymorphic variant of the IL1β gene in patients with PIE showed a significant relationship between their frequency distribution and the presence/absence of gliosis phenomena (p=0.009). Thus, gliosis was detected in all carriers of the T/T genotype C3953T polymorphic variant of the IL1β gene. Analyzing the dependence of changes obtained during the transcranial Doppler ultrasound scanning of cerebral vessels on the polymorphic variant C3953T of the IL1β gene in patients with PIE, all carriers of the T/T genotype were diagnosed with angiospasm (p=0.038) and vertebrobasilar insufficiency (p=0.010).&#x0D; Conclusions: Results suggest the reasonability of further researching the interaction between IL1β and glial cells and changes in the cognitive functioning of cytokine genotypes with larger sample sizes that may help explain the pathophysiological mechanisms leading to cognitive impairment in patients with PIE.

Vertebrobasilar Insufficiency Syndrome in Extension: Insights into Surgical Treatment

Rotational vertebrobasilar artery syndrome, or bow hunter syndrome, is a rare yet well-documented pathology. This study presents a surgical approach to a latent manifestation of dynamic, extension-only, bilateral codominant vertebral artery compression in the V3 segment, associated with craniocervical instability and central canal stenosis. The clinical presentation involves the treatment of positional vertigo resulting from left and high-grade right vertebral artery stenosis during neck extension only. Diagnosis was confirmed through a formal angiogram under provocative maneuvers. Surgical intervention, detailed in this section, employed a multidisciplinary approach, including intraoperative angiograms to ensure patent vertebral arteries precraniocervical fusion. The surgical treatment demonstrated success in addressing extension-only vertebrobasilar syndrome and associated complications of C1-2 pannus and craniocervical instability. Intraoperative angiograms confirmed vertebral artery patency pre- and postsurgical positioning, ensuring the effectiveness of the multidisciplinary approach. This study concludes by highlighting the successful multidisciplinary surgical treatment of a patient with nonunion of a C1 Jefferson fracture, leading to extension-only vertebrobasilar syndrome complicated by C1-2 pannus and craniocervical instability. The importance of considering vertebral artery dynamic stenosis in cases of positional vertigo or transient neurological symptoms following an injury is emphasized. Surgical stabilization, particularly when conservative measures prove ineffective, is recommended, with careful attention to pre- and postsurgical positioning to verify vertebral artery patency and posterior vasculature integrity.

Changes in cerebral hemodynamic parameters for patients with encephalopathies of different genesis

Mental function impairment is a common sign of encephalopathies, which various factors, including neurological disorders and cerebral hemodynamics, can cause.The purpose of the study was to establish changes in cerebral hemodynamic parameters in patients with encephalopathies of various origins.Material and methods. 520 patients with chronic traumatic encephalopathy (CTE, n=145), vascular encephalopathy in chronic brain ischemia (CVE, n=145), chronic alcoholic encephalopathy (CAE, n=102) and post-infectious encephalopathy (PIE, n=128) were examined. The patients were receiving inpatient treatment on the basis of the communal non-profit enterprise "Ternopil Regional Clinical Psychoneurological Hospital" during the period of 2021-2022. The cerebral blood flow was assessed using transcranial doppler scanning of intracranial and extracranial brachiocephalic vessels on a Philips HDI device.Research results. The most frequent disorders of cerebral hemodynamics in patients with CTE are the following: insufficient blood flow (44.83%), angiospasm (44.14%) and stenosis (40.69%); in patients with CVE – stenosis (67.59%), insufficient blood flow (66.21%) and venous stasis (64.83%); in patients with CAE – insufficient blood flow (32.35%), angiospasm (31.37%) and venous stasis (30.39%); in patients with PIE - angiospasm (45.31%), blood flow insufficiency (37.50%) and vertebro-basilar insufficiency (30.47%). Comparing the parameters of cerebral hemodynamics in patients with encephalopathies of various genesis, it was established that angiospasm in patients with CVE was recorded more often (by 23.11%) than in patients with CAE. A similar trend was noted in patients with CTE and PIE relative to the CAE group. The frequency of registration of blood flow insufficiency in patients with CVE probably exceeded the data of groups of CTE, CAE, and PIE (by 21.38, 33.86, and 28.71%, respectively). At the same time, the presence of changes within two distribution zones - carotid cerebral and vertebral-basilar in patients with CVE probably exceeded the data of the CAE and PIE groups. Regarding the comparison of the characteristics of stenoses, the frequency of detection of this phenomenon in patients with CTE probably exceeded the data of the CTE, CAE, and PIE groups (by 26.90, 53.86, and 64.46%, respectively). At the same time, the proportion of patients with significant stenosis in the CTE group probably exceeded the data of the CVE, CAE and PIE groups. The highest frequency of registration of venous stasis was established in patients with CTE (64.83%), which probably exceeded the data of the CTE, CAE and PIE groups. Vertebro-basilar insufficiency was not detected in patients with CAE, and in the PIE group its frequency of registration was 14.61% higher than the data of the CVE group and 18.06% higher than the data of the CTE group.Conclusions. The obtained results indicate the heterogeneity and polymorphism of the parameters of cerebral hemodynamics in patients with encephalopathies of various genesis, which requires further research to find possible relationships between them and cognitive dysfunction.

WITHDRAWN: A narrative review of techniques for surgical revascularization of the extracranial vertebral artery in vertebrobasilar insufficiency

Vertebrobasilar insufficiency is a condition characterized by poor blood flow through the posterior circulation of the brain, which supplies the brainstem, thalamus, hippocampus, cerebellum, occipital lobes, and medial temporal lobes. Narrowing or occlusion of the vertebral arteries may be result in a range of neurological symptoms, including dizziness, imbalance, dysarthria, and even stroke. If symptomatic patients fail medical management, revascularization of the vertebral artery should be considered. Restoration of blood flow may involve transluminal balloon angioplasty or stent placement; however, certain cases may still require surgical intervention. The complexity of surgical revascularization of the vertebral artery requires careful consideration of skull base and neck anatomy. This review article will focus on bypass of the vertebral artery in the setting of ischemic pathology, describing the technique, anatomical nuances, steps involved in preoperative planning, and postoperative management.

ACE and AT2R1 gene polymorphism in patients with chronic vascular encephalopathy: association with neuroimaging changes and cognitive functioning

Background. Given the synergistic effect of the ACE and AT2R1 genes and their impact on the maintenance of homeostatic processes, the aim of our research was to identify the associations of the studied polymorphic variants of the ACE and AT2R1 genes with neuroimaging changes, data from arterial duplex ultrasound and cognitive functioning in patients with chronic vascular encephalopathy (CVE). Materials and methods. A retrospective analysis of 145 medical records of patients with CVE was conducted, of which 18 patients underwent a molecular genetic study. The control group consisted of 12 people representative in terms of age and gender. Neuroimaging was performed using multislice computed tomography or magnetic resonance imaging. The state of cerebral blood flow was studied using transcranial duplex ultrasound of intracranial and extracranial vessels. The cognitive functioning was tested using the Montreal Cognitive Assessment. Results. When analyzing the associations of polymorphic I/D variants of the ACE gene and A1166C of the AT2R1 gene with neuroimaging changes and parameters of cerebral hemodynamics in CVE among carriers of I and D alleles of the ACE gene, a probable relationship was found between their frequency distribution and the presence/absence of gliosis phenomena (62.69 % of D allele carriers were diagnosed with gliosis, p &lt; 0.05); a probable relationship between the frequency distribution of the D/D genotype of the ACE gene and the presence of angiospasm (in 72.73 % of patients), insufficiency of blood flow in the carotid system (72.73 % of cases) and vertebrobasilar insufficiency (in 36.36 % of people). When evaluating the dependence of cognitive functions based on the Montreal Cognitive Assessment score in patients with CVE on the polymorphic I/D variants of the ACE gene and A1166C of the AT2R1 gene, probable changes were revealed in the frequency distribution of genotypes and alleles of the polymorphic I/D variant of the ACE gene (χ2 = 11.33; p = 0.023), while all carriers of the D/D genotype have impaired cognitive functioning (moderate in 36.36 % and mild in 63.64 % of cases), which also corresponds to the frequency of the D allele distribution in this cohort of patients (29.63 % of people have a moderate cognitive impairment and 70.37 % — a mild cognitive impairment, p = 0.013). Conclusions. The study results indicate that the ACE gene may be involved in the development of neuroimaging changes and cognitive decline in CVE.

Abstract 114: “Failing” DAPT? Think Again

Introduction Bow Hunter’s Syndrome (BHS) is a rare etiology of vertebrobasilar insufficiency that usually occurs with head turn, which causes compression of the vertebral artery by an osteophyte. There is subsequent hypoperfusion of brain tissue, but thromboembolism and ischemic stroke is rare. Timely diagnosis is imperative, as decompressive surgery can be curative. This unique case highlights the diagnostic and therapeutic challenges of a patient with multiple vascular risk factors who suffered from strokes secondary to BHS. Methods A 79‐year‐old man with a past medical history of peripheral artery disease, abdominal aortic aneurysm, myocardial infarction with drug eluding stents (on dual antiplatelet therapy (DAPT)), complete heart block with pacemaker, heart failure with reduced ejection fraction, hypertension, hyperlipidemia, and diabetes mellitus presented to an outside hospital with recurrent episodes of right‐sided weakness every 1‐2 days over the previous 3 weeks. Episodes always occurred after activity and only upon sitting. He had previously undergone non‐contrasted head computed tomography (NCHCT) (magnetic resonance imaging (MRI) was unable to be performed secondary to pacemaker), which did not reveal strokes. His initial computed tomography angiogram (CTA) of the head and neck was unremarkable. However, CTA head and neck 4 days later demonstrated 90 percent stenosis of the mid left V2 at the C3‐4 level and a 75‐90 percent stenosis of the left mid V2 segment at the C5‐6 level (hard and soft plaque in these areas). He was switched from DAPT to aspirin and warfarin because he was considered a “DAPT failure.” He continued to have episodes, so he was transferred to our institution for a second opinion. Results On arrival, the exam was notable for right‐sided hemiparesis and dysmetria. Repeat CTA head and neck demonstrated multifocal intracranial atherosclerosis with marked stenosis of the left V4 segment. However, marked stenosis at V2 appeared to be owed to external compression from facet arthrosis rather than atherosclerosis. He also had moderate stenosis of the right V4 segment. Eventually, he underwent an MRI brain, which demonstrated acute to subacute infarcts in the left pons. He was taken for a cerebral angiogram on the same day, which demonstrated stenosis of the distal V2 segment of the left vertebral artery (at the level of C3‐C4) with interval development of marked stenosis following neck flexion and occlusion of the left vertebral artery following leftward head rotation. Findings were most consistent with rotational occlusion of the left vertebral artery, which is also known as BHS. The patient underwent surgery, but suffered from a gastrointestinal bleed and developed post‐operative atrial fibrillation; after a risks/benefits discussion, he was discharged on anticoagulation only. He had no further strokes. Conclusion This patient suffered from ischemic strokes, which occur in less than 10% of BHS cases. Contralateral vertebral artery stenosis, which is unable to supply retrograde flow during compression, is the likely etiology of this patient's strokes. Recurrent posterior circulation strokes in the setting of optimal medical management should clue clinicians to consider other etiologies of stroke. Dynamic angiography is the gold standard for BHS and decompressive surgery is often curative.

Abstract 286: Endovascular Management of Pediatric Vertebro‐Vertebral Arterio‐Venous Fistula: Case report

Introduction Vertebro‐vertebral arteriovenous fistula (VV‐AVF) is a rare vascular malformation with abnormal high flow shunt between extracranial vertebral artery and an adjacent vertebral vein plexus without intervening capillaries.1 While seen in both adult and pediatric populations, the majority of the VV‐AVFs seen in childhood are largely congenital, seen in the setting of connective tissue diseases such as Ehler‐Danlos Syndrome, Neurofibromatosis type 1, and Marfan’s syndrome, with abnormal involution of the proatlantal system also thought to be implicated.2,3,4 Approximately 70% of the presenting population are symptomatic at presentation, with a pulsatile mass over the side of the neck or pulsatile tinnitus. Additionally, symptoms of vertebrobasilar insufficiency including gait abnormalities, limb weakness, vertigo, recurrent vomiting, diplopia, and in severe cases, cardiac decompensation can also be seen.5 Methods This is a case report of a 2‐year‐old boy presented to our pediatric neurovascular center of excellence with a progressively enlarging pulsatile left neck mass appreciated a year ago. Further evaluation with neck MRA followed by catheter cerebral angiogram revealed an upper cervical AVF with primary arterial feeders from V3 segment of the left vertebral artery, enlarged left occipital artery, and retrograde filling via the right vertebral artery into the left V4 with a direct shunt into a large venous pouch which drained into the vertebral venous plexus. Results Given the progressive enlargement of the mass, location of AVF, and concern for detrimental subsequent venous congestion, decision was made to pursue elective endovascular embolization of the VV‐AVF. The goal was set to obtain complete occlusion of the venous pouch to obliterate all arterial inflow contribution and prevent further recruitment. Occipital artery catheterization was attempted however given the redundant anatomical loops; optimum microcatheter navigation was not feasible. Given the non‐dominant configuration of the left VA, along with the presence of left AICA‐PICA system off the basilar trunk, coil embolization of the venous pouch followed by sacrifice of the V3 segment left VA was achieved satisfactorily leading to obliteration of the AVF along with all the arterial contributions from bilateral vertebral arteries and left occipital artery (Figure‐1). Given the potential vertebrobasilar inadvertent embolization, the procedure was performed under continuous neurophysiological monitoring and post‐periprocedural therapeutic anticoagulation. The patient tolerated the procedure well without any intraoperative issues. He was monitored in the pediatric ICU for 24 hours after the procedure, and subsequently discharged home. Conclusion We report a successful endovascular coil embolization of a VV‐AVF. To our knowledge, this is the youngest reported case where endovascular technique was successfully utilized to achieve cure of such high flow VV‐AVF in this 2‐year‐old patient. Systematic and methodical angiographic analyses with close post‐procedural monitoring are pivotal in ensuring successful outcomes.

Clinical findings in patients with vertebrobasilar insufficiency

The vertebrabasilar (VB) system plays an essential role in the circulation of main structures of nervous system. As a part of Circle of Willis, it is responsible for major compensatory abilities of brain circulation in some hemodynamic disorders. On the other hand, some pathological diseases, involving VB system, could be fatal or could lead to severe injuries and functional wastes in the patient. Many variations and anomalies in VB system are common cause of hemodynamic disorders and vascular disease such as atherosclerosis. The good knowledge of variations and anatomy as well, allows us to understand pathophysiology and pathogenesis in those disorders, which in combination with specific clinical symptoms, helps us in making the fast and accurate diagnosis. This is fundamental for starting proper treatment.

The clinical efficacy and safety of Ginkgo biloba in vertigo patients: A meta-analysis

ObjectiveWe detected the clinical efficacy and safety of Ginkgo biloba in vertigo patients through a meta-analysis method. MethodPubMed, Web of Science, Embase, Cochrane, EBSCO, CBM, CNKI, and Wanfang databases were searched for randomized controlled trials. Data about the clinical efficacy and safety of vertigo patients were collected. The Ginkgo biloba groups were pooled to compare with the control groups and obtain the pooled odds ratios and associated 95 % confidence interval. ResultsWe retrieved 25 randomized controlled studies enrolling 1209 patients. The addition of Ginkgo biloba improved vertigo in patients with vertebrobasilar artery insufficiency, cervical vertigo, and not-specific-disease vertigo but not in BPPV and Meniere’s disease. The incidence of adverse reactions such as headache, gastrointestinal discomfort, and skin rashes in the Ginkgo biloba group did not differ significantly from that of the control group. ConclusionThe addition of Ginkgo biloba had better clinical efficacy in patients with vertebrobasilar artery insufficiency, cervical vertigo, and not-specific-disease vertigo but not in BPPV and Meniere’s disease, and the Ginkgo biloba group had no significant differences in adverse reactions compared with the control group.