Vertebrobasilar Stroke Research Articles

Clinical characteristic and long-term prognosis in vertebrobasilar stroke

Vertebrobasilar stroke (VBS) is 20-25% of the ischemic stroke structure, however, the clinical features and long-term outcome of the disease studied poorly in the domestic population.The aim of the study was to analyze the clinical features of the acute period of VBS and calculate the 5-year risk of cardiovascular events and death.Material and methods. We analyzed the data of 1569 patients with ischemic stroke. There were analyses of patient complaints, neurological status, brain imaging, NIHSS and POST-NIHSS. The logistic regression model was built for an integral assessment of predictors of five-year mortality.Results. 386 (25%) patients with VBS were diagnosed and 147 (9,4%) cases of VBS were diagnosed with CT-scan. The top complaints were dizziness, unsteadiness and blurred speech. 72 (48,9%) patients were low neurological deficit, the most common neurological syndromes were ataxia, prosoparesis, hemiparesis, dysarthria and nystagmus. More than 60% of patients had an unspecified stroke subtype, despite the diagnostic search performed. The 19,4% patients were recurrent ischemic stroke and 37,2% patients died. Predictors of mortality were age and the presence of cardiovascular disease. Conclusion. Patients with VBS are characterized by a predominantly nonspecific clinical picture of the disease, in half of the cases a minor neurological deficit, insufficient information content of the initial computed tomography of the brain, a low frequency of intravenous thrombolysis, difficulties in determining the cause of stroke and a high risk of recurrent stroke and death within 5 years.

Vertigo as Initial Symptom of Cerebellar Hemorrhage in Adult Woman : A Case Report

Vertigo, difficulty walking, and loss of balance/coordination are among the symptoms of stroke in 50% of stroke cases. Vertigo due to cerebrovascular disease is generally associated with other neurological signs such as cranial nerve abnormalities, hemiparesis, facial weakness, diplopia, hyperesthesia, and Horner's syndrome. A 42-year-old woman came to the emergency department with complaints of dizziness, nausea, and frequent vomiting for the previous 4 hours. The symptoms are also accompanied by a feeling of tingling on the left side of the face, and the left eyelid cannot open optimally. The patient has a history of uncontrolled hypertension. The HINTS test revealed central vertigo, and the patient also found dysdiadochokinesis, ataxia, and dysmethria. A non-contrast head CT scan showed ICH in the left cerebellum with a volume of 6.9 cc. Based on the results of these examinations, the patient was diagnosed with cerebellar hemorrhage. The blood supply to the brainstem, cerebellum, and inner ear comes from the vertebrobasilar vascular system. Blockage or rupture of blood vessels in one of the main branches of this system can cause symptoms of vertigo. Symptoms of vertebrobasilar stroke vary widely and depend on which of the three main circumferential branches is affected; posterior inferior cerebellar artery, anterior inferior cerebellar artery, or superior cerebellar artery. Vertigo in patients who have risk factors for stroke accompanied by other neurological symptoms should be considered for a thorough neurological examination to evaluate the possibility of cerebrovascular disease.

Mechanical Thrombectomy for Hyperacute Vertebrobasilar Ischemic Stroke via Nondominant Vertebral Artery : Clinical Experience and Considerations.

The dominant vertebral artery (VA) approach is primarily considered in mechanical thrombectomy (MT) for acute occlusion of the vertebrobasilar (VB) artery. As accessing the dominant artery is sometimes difficult, we present our experience treating acute VB stroke via a nondominant VA approach through a comparison with the dominant VA approach. Among 2,785 patients diagnosed with hyperacute ischemic stroke between January 2014 and December 2022, 50 patients with VB ischemic stroke underwent recanalization therapy through either dominant, nondominant, or bilateral VA approach. We evaluated patient characteristics and clinical course, highlighting the pros and cons of the access routes. The patients with hyperacute VB ischemic stroke were predominantly male (72%), with a mean age of 68.12 years and an initial National Institutes of Health Stroke Scale (NIHSS) score mean of 17.1. Large-artery atherosclerosis (LAA, 48%) and cardio-embolism (CE, 36%) were the main etiologic factors in the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. After thrombectomy, 45 (90%) cases had final modified thrombolysis in cerebral infarction (mTICI) score of 2b or higher. In summary, 41 patients were treated through the dominant VA, and 8 patients underwent the nondominant VA approach. However, there was no statistically significant difference in functional outcome or mortality between the two approaches. In MT for VB occlusions, nondominant VA approach may be an option in situations when the vessel is accessible, stable, or less risky, as recanalization can be achieved without rescue balloon angioplasty and/or stenting.

Percutaneous transluminal angioplasty and stenting (PTAS) in patients with symptomatic intracranial vertebrobasilar artery stenosis (IVBS)

BackgroundApproximately 20% of all transient ischaemic attacks (TIAs) and ischaemic strokes occur within the posterior circulation, with vertebrobasilar stenosis identified as the cause in roughly 25% of the cases. Studies...

A acute pontine infarction with one-and-a-half syndrome as the manifestation: A case report.

Sudden ocular dyskinesia is usually associated with ophthalmic diseases and rarely with cerebrovascular diseases. This is a rare case of a patient with a sudden onset of ocular dyskinesia due to occlusion of the anterior inferior cerebellar artery and the spiral modiolar artery. This article describes eye movement disorders associated with cerebrovascular disease, aiming to improve our understanding of cerebrovascular diseases and improve the ability of early diagnosis and differential diagnosis. A 52-year-old man presented with acute pontine cerebral infarction 2 days before presentation. The main symptoms were the inability to adduct and abduct the left eyeball, the ability to abduct but not adduct the right eyeball, and horizontal nystagmus during abduction. Cranial computed tomography in our emergency department suggested cerebral infarction, and magnetic resonance imaging examination after admission confirmed the diagnosis of acute pontine cerebral infarction. This patient was ultimately diagnosed with acute pontine cerebral infarction. He received aspirin, clopidogrel, and butylphthalide, as well as acupuncture and Chinese herbal medicine. After 10 days of treatment, the patient's paralysis of the eye muscles improved significantly. Eye movement disorders are sometimes an early warning sign of impending vertebrobasilar ischemic stroke. Patients with acute ischemic stroke who have early detection of oculomotor disturbances should be promptly imaged, as missed diagnosis may lead to serious consequences or even death. It provided us with a new diagnostic idea.

Experimental comparison of first-pass effect between direct thromboaspiration and combined thrombectomy in the setting of distal basilar occlusion.

Studies investigating endovascular therapy in vertebro-basilar stroke have led to controversial results in the past, but recent randomized trials seem to show an effectiveness superiority of endovascular therapy versus best medical treatment. However, uncertainty remains concerning many aspects of thrombectomy in acute basilar artery occlusion, notably technical considerations. This study compared the first-pass effect of direct thromboaspiration and combined thrombectomy in the setting of distal basilar occlusion. An in-vitro experimental set-up was used, consisting of a vascular phantom model and thrombus analogs of different consistencies to mimic human clots. Thrombus analogs were injected into the model through the vertebral artery and flowed to the basilar distal third to mimic a distal basilar occlusion. Ten procedures were performed for each thrombus analog stiffness and technique (direct thromboaspiration versus combined thrombectomy). Direct thromboaspiration showed an overall first-pass effect rate of 83.3% (25/30) and was particularly effective for ultra-soft and soft clot analogs, but decreased for hard clot analogs. Combined thrombectomy had an overall first-pass effect rate of 56.7% (17/30). The effect rate for ultra-soft and soft clot analogs was 60% and 50% for hard clot analogs. In the softer clot analogs, the stent-retriever device used for the combined thrombectomies tended to deviate the clot analog from a co-axial trajectory with the aspiration catheter. In the context of distal basilar occlusion, our in-vitro results showed that higher first-pass effect rates were achieved with direct thromboaspiration compared to combined thrombectomy in all types of thrombus analogs.

Novel use of a closed-tip stent retriever to prevent distal embolism in the posterior circulation: illustrative case.

In mechanical thrombectomy for tandem occlusions in vertebrobasilar stroke, distal emboli from the vertebral artery lesion should be prevented. However, no suitable embolic protection devices are currently available in the posterior circulation. Here, the authors describe the case of a vertebral artery lesion effectively treated with a closed-tip stent retriever as an embolic protection device in the posterior circulation. A 65-year-old male underwent mechanical thrombectomy for basilar artery occlusion, with tandem occlusion of the proximal vertebral artery. After basilar artery recanalization via the nonoccluded vertebral artery, a subsequent mechanical thrombectomy was performed for the occluded proximal vertebral artery. To prevent distal embolization of the basilar artery, an EmboTrap III stent retriever was deployed as an embolic protection device within the basilar artery to successfully capture the thrombus. A stent retriever with a closed-tip structure can effectively capture thrombi, making it a suitable distal embolic protection device in the posterior circulation.

The Role of Transcranial-Color-Doppler in the Management of Basilar Artery Stenosis: Case Series and Systematic Review of Literature

Managing vertebrobasilar (VB) stroke, particularly basilar artery occlusion (BAO), presents challenges due to diverse clinical presentations and intricate diagnostics, risking delays in acute-phase reperfusion therapies. The diagnostic complexities of VB stroke prompt questions about whether presentation tempo influences outcomes. For non-urgent cases of basilar artery stenosis (BAS) lacking guidelines, clinical management becomes case-dependent. Current options include aggressive medical therapy (AMT) and percutaneous transluminal angioplasty and/or stenting (PTAS). However, the choice of PTAS remains debated, with recent trials observing higher-than-expected recurrence rates, particularly in intracranial stenosis. Understanding hemodynamic status is crucial in predicting stroke risk, especially in atherosclerotic VB disease. Recent studies highlighted the role of distal flow status in predicting stroke risk, emphasizing the importance of hemodynamic assessment beyond anatomic measures. Neurosonology, especially transcranial color-coded duplex sonography (TCCS), emerges as a valuable tool for assessing hemodynamics. Despite TCCS being operator-dependent and technically challenging for BAS evaluation, it effectively detects significant hemodynamic changes, providing real-time information on collateral flow. This review explores the potential role of TCCS in managing BA hemodynamic failure in VB stroke, with particular regard to the selection of BAS patients who may benefit from PTAS.

Association between vertebrobasilar artery geometry and vertebrobasilar stenosis, recurrence, and death in posterior circulation stroke and transient ischemic attack

BackgroundIntracranial atherosclerosis is one of the primary causes of posterior circulation stroke and transient ischemic attack (TIA), particularly in people of South and East Asian heritage. Focal vessel geometry may play a role in atherosclerosis progression. Thus, we investigated the relevance of vertebrobasilar artery (VBA) geometry and vertebrobasilar atherosclerotic stenosis, recurrence, and death in posterior circulation stroke and TIA. MethodsFour hundred and twenty patients with posterior circulation ischemic stroke or TIA were included. The VBA geometric features, comprising the geometric configurations (Tuning fork, Walking, Lambda, and No confluence), vascular bends (multi-bending and oligo-bending), and VBA stenosis degrees, were defined based on computed tomography angiography (CTA) images. Recurrence of stroke or TIA and death were assessed through a 1-year follow-up. Additionally, the relationship between VBA geometric features, VBA stenosis, and prognosis were analyzed. ResultsWalking type and vascular multi-bending showed significant associations with more severe VBA stenosis and distribution, and these were also more frequently observed in patients with large-artery atherosclerosis (LAA) stroke (all P < 0.05). Sixty-four patients exhibited recurrent stroke or TIA, and 31 died during the 1-year follow-up. In the binary logistic regression analysis, Walking type (P = 0.018), Lambda type (P = 0.021), and multi-bending type (P = 0.004) were found to be independently associated with stroke recurrence, while No confluence type was independently associated with death (P = 0.010). ConclusionsThe geometric characteristics of the VBA are associated with vertebrobasilar stenosis, LAA stroke, 1-year recurrence, and death in posterior circulation stroke and TIA. VBA geometry may be used to stratify the risk of stroke and TIA in the posterior circulation.

Tratamiento endovascular del ictus isquémico vertebrobasilar en Aragón: características clínicas, radiológicas, tiempos de atención y pronóstico a los 3 meses

IntroductionPosterior circulation stroke accounts for 15%-20% of ischaemic strokes, but is associated with poor functional and vital prognosis in over 60% of cases. Due to its clinical and radiological peculiarities, diagnosis and management are more complex than in anterior circulation stroke. This study analyses and characterises patients with vertebrobasilar strokes treated with mechanical thrombectomy in our region. MethodsWe conducted a descriptive, retrospective analysis of patients with vertebrobasilar stroke and treated with mechanical thrombectomy at our centre, a reference centre for cerebrovascular emergencies for the region of Aragon. We recorded baseline characteristics, risk factors, signs and symptoms at onset, radiological assessment scale scores, procedure-related variables, management times, and functional prognosis at 3 months. ResultsWe selected 37 patients (39.5% women; mean age [standard deviation], 68.34 [14.1] years). Cardioembolic stroke (42.1%) was the most common aetiology, followed by atherothrombosis (28.9%). The top of the basilar artery was the most common site of obstruction (55.3%). The most frequent clinical features were somnolence (76.3%), motor deficits (71.1%), and nausea (55.3%). Successful reperfusion (mTICI ≥ 2b) was achieved in 81.1% of patients. Functional outcome at 90 days was poor (mRS < 3) in 59% of patients. ConclusionsPosterior circulation stroke is associated with high rates of morbidity and mortality. Its subacute, nonspecific clinical course prolongs management times and hinders early detection. Mechanical thrombectomy is a safe and effective procedure, although further studies are needed to establish the optimal patient profile.

Low-flow extra-intracranial bypass in acute carotid and vertebrobasilar ischemic stroke (literature review)

Introduction. The effectiveness of the method of revascularization of the brain using extra‑intracranial bypass in chronic insufficiency of blood supply to the brain has been studied in several randomized multicenter studies. The analysis of available publications devoted to this technique for 10 years with acute strokes in the carotid basin and for 20 years with ischemic strokes in the vertebrobasilar basin was carried out.Aim. To improve the results of treatment of ischemic strokes with the help of emergency extra‑intracranial low‑flow bypasses in the acute and acute period. In 12 publications over the past 10 years, selected from the PubMed search engine, 194 cases of the use of emergency extra‑intracranial microbypasses in the acute and acute period of ischemic stroke in the carotid basin were identified, 127 cases of emergency extra‑intracranial bypass were found in 6 articles during the last 20 years in the acute phase of vertebra‑basilar area stroke. Middle patient age in carotid group was 61.9 years, and 65 years in vertebral patient’s group. The male / female ratio was 3 / 1. The main indications for the bypass creation were: worsening of neurologic deficit from 4 and more according to the Stroke Severity Scale of the US National Institutes of Health, mini mal or not significant computed tomography (CT) or diffusion‑weighted magnetic resonance imaging (DW‑MRI) ischemia brain changes (not lower than 8 points on the scale of assessment of initial changes in the computed tomographic (CT) examination for stroke Alberta Stroke Program Early CT Score, ASPECTS), signs of significant brachiocephalic arteries atherosclerotic stenosis. In 83 carotid group cases perfusion‑diffusion mismatch was distinguished before bypass creation. In 111 carotid cases and in priority of vertebra‑basilar cases clinic‑diffusion mismatch was the only indication for emergency extra‑intracranial bypass creation. During the first 24 hours 65 % of carotid group bypass were performed, in other 35 % of cases bypasses were performed during 1 week after the stroke onset. There were 78 % of good results (&lt;2 on the Rankin outcome scale, mRS) and 22 % of poor (mRS &gt;2) in carotid stroke group. Mortality was 3 %. In vertebral group, coma was not contraindication for emergence extra‑intracranial bypass creation. In most cases, 70 % of bypass were performed between superficial temporal artery and superior cerebellar artery. Mortality in vertebral stroke group was 5 %, mostly because of somatic pathology worsening. Good results were achieved in76 % of cases.Conclusion. In some cases of atherosclerotic carotid and vertebrobasilar ischemic stroke, results of recovery can be approved greatly with use of emergency low‑flow extra‑intracranial bypass, if intravenous thrombolysis and endovascular tromboextraction were failed.

Giant cell arteritis with vertebral artery involvement-baseline characteristics and follow-up of a monocentric patient cohort.

Vertebral artery (VA) involvement in giant cell arteritis (GCA) has rarely been reported. We aimed to evaluate the prevalence, patients' characteristics, and immunotherapies used in patients with GCA and VA involvement at diagnosis and 1 year follow-up, retrospectively including patients being diagnosed between January 2011 and March 2021 in our department. Clinical features, laboratory data, VA imaging, immunotherapy, and 1 year follow-up data were analyzed. Baseline characteristics were compared to GCA patients without VA involvement. Among all 77 cases with GCA, 29 patients (37.7%) had VA involvement, as diagnosed by imaging and/or clinical signs and symptoms. Gender distribution and erythrocyte sedimentation rate (ESR) were significantly different in the groups with and without VA involvement, with more women being affected (38/48 patients, 79.2%) and a significantly higher median ESR in patients without VA involvement (62 vs. 46 mm/h; p = 0.012). MRI and/or CT showed vertebrobasilar stroke at GCA diagnosis in 11 cases. 67/77 patients (87.0%) received high-dose intravenous glucocorticosteroids (GCs) at diagnosis, followed by oral tapering. Six patients were treated with methotrexate (MTX), one with rituximab, and five with tocilizumab (TCZ). 2/5 TCZ patients achieved clinical remission after 1 year, vertebrobasilar stroke within the first year occurred in 2/5 patients. Diagnosis of VA involvement might be underrecognized in GCA patients. VA imaging should be performed in elderly patients with vertebrobasilar stroke presenting with GCA symptoms, not to miss GCA as the etiology of stroke. Efficacy of immunotherapies in GCA with VA affection and long-term outcomes need to be investigated further.

Diagnosis of dizziness in the emergency department: A 1-year prospective single-center study.

The management of dizziness and vertigo can be challenging in the emergency department (ED). It is important to rapidly diagnose vertebrobasilar stroke (VBS), as therapeutic options such as thrombolysis and anticoagulation require prompt decisions. This study aims to assess the rate of misdiagnosis in patients with dizziness caused by VBS in the ED. The cohort was comprised of 66 patients with a mean age 56 years; 48% were women and 52% men. Among dizzy patients, 14% had VBS. We used Cohen's kappa test to quantify the agreement between two raters -namely, emergency physicians and neurologists -regarding the causes of dizziness in the ED. The Kappa value was 0.27 regarding the final diagnosis of central vertigo disorders and VBS, thus showing the low agreement. We used the χi2 test to show the association between the presence of two or more cardiovascular risk factors and admission to the stroke unit (p = 0.015). There is a substantial rate of misdiagnosis in patients with dizziness caused by VBS in the ED. To reduce the number of missing diagnoses of VBS in the future, there is a need to train emergency physicians in neurovestibular examinations, including the HINTS examination for acute vestibular syndrome (AVS) and the Dix-Hallpike (DH) maneuver for episodic vestibular syndrome. Using video head impulse test could help reduce the rate of misdiagnosis of VBS in the ED.

Síndrome del uno y medio secundario a ataque cerebrovascular isquémico vertebrobasilar

El síndrome del uno y medio es una entidad que se caracteriza por parálisis de la mirada conjugada horizontal y alteración del fascículo longitudinal medial (FLM) ipsilateral secundario a diversas etiologías, entre las que se incluye el ataque cerebrovascular (ACV). Se describen dos casos de pacientes que consultaron por hemiparesia, incapacidad para realizar movimientos horizontales en uno de los ojos y abducción forzada del ojo contralateral e imposibilidad para la aducción. En ambos casos los estudios demostraron la presencia de un ACV isquémico vertebrobasilar como origen del síndrome; el reconocimiento de la fisiología de la mirada conjugada es fundamental en el abordaje del paciente y permite realizar un diagnóstico exacto a partir de una historia clínica detallada y una evaluación física minuciosa.

Stroke and peripheral vestibulopathy as a part of acute vestibular syndrome

The scope of the review is the problem of differential diagnosis between stroke and peripheral vestibulopathy in patients with acute vestibular vertigo. A vertebrobasilar stroke manifesting with the isolated vertigo has been previously recognized to be extremely rare, and the symptoms have been related to the involvement of peripheral parts of the vestibular analyzer. Recently there has been growing evidence that the isolated vertigo syndrome is commonly related to the central involvement of the vestibular analyzer. The author presents published clinical cases of acute cerebrovascular accident with a single symptom of acute vestibular vertigo. It can be also a symptom of a hemispheric stroke due to an injury of vestibular pathways connecting the vestibular nuclei with the parietal cortex. These observations extend the understanding of the common classic pathognomonic picture of central vestibular vertigo, which implies that its development is related exclusively to the brain matter lesion in vestibulobasilar stroke.&#x0D; Current clinical rating scales and tests (NIHSS, FAST) used for the diagnosis of an acute stroke, are frequently not sensitive to the vertebrobasilar stroke, and neuroimaging, including brain magnetic resonance imaging at DWI mode, may give false negative results. The most informative differential diagnostic method in acute vestibular syndrome is an otoneurological assessment including identification of nystagmus characteristics and head turn impulse test, for the assessment of vestibuloocular reflex and at bed tests (for example, tests included into the HINTS PLUS protocol). In this regard, it is important that neurology specialists in regional vascular centers and departments for acute cerebrovascular care should master the otoneurological assessment skills.

Craniovertebral junction aneurysms

ObjectiveThe course of the vertebral artery and its relationship to the C0–1–2 structures render it particularly vulnerable to mechanical trauma. In the present study, we investigated the course of vertebral arteries along the craniovertebral junction (CJ) to cast light on the biomechanical aspects of aneurysm formation, focusing mainly on the relation of the vertebral artery injuries to the CJ bony landmarks. Herein, we report our experience with fourteen cases of craniovertebral junction vertebral artery (CJVA) aneurysms and their presentations, management, and outcomes. Materials and methodsWe extracted from 83 vertebral artery aneurysms only those 14 cases whose aneurysms were located at the C0–1–2. We reviewed all medical records, including operative reports and radiologic images. We divided the CJVA into 5 segments and then carefully reviewed the cases, largely focusing on the CJVA segments involved in the aneurysm. Angiographic outcomes were determined by angiography, which was scheduled at 3–6 months, 1, 2.5, and 5 years postoperatively. ResultsA total of 14 patients with CJVA aneurysms were included in the present study. 35.7 % had cerebrovascular risk factors, while 23.5 % had other predisposing factors such as an AVM, an AVF, or a foramen magnum tumor. Predisposing factors in the form of neck trauma, both direct and indirect, were identified in 50 % of cases. The segmental distribution of aneurysms was as follows: three (21.4 %) at CJV 1, one (7.1 %) at CJV 2, four (28.6 %) at CJV 3, two (14.3 %) at CJV 4, and four (28.6 %) isolated to the CJV 5 segment. Of the 6 indirect traumatic aneurysms, 1 (16.7 %) was located at CJV 1, 4 (66.7 %) were located at CJV 3 and 1 (16.7 %) was located at CJV 5. The 1/1 direct traumatic aneurysm (100 %) from the penetrating injury was located at CJV 1. 100 % of cases with cerebrovascular risk factors, the affected vessels were on the dominant side. 42.9 % of cases presented symptoms of a vertebrobasilar stroke. All 14 aneurysms were managed only endovascularly. 85.8 % of patients we implemented flow diverters only. 57.1 % of follow-up cases were completely occluded angiographically, and 42.9 % of cases were near-completely or incompletely occluded at 1, 2.5, and 5-year follow-ups. ConclusionsThe current article is the first report of a series of vertebral artery aneurysms located in CJ. Herein, the association of vertebral artery aneurysm, hemodynamics, and trauma is well established. We clarified all segments of the CJVA and showed that the segmental distribution of CJVA aneurysms significantly differs between traumatic and spontaneous cases. We showed that treatment with flow diverters should be the mainstay of CJVA aneurysm treatment.

Ischemic stroke in a patient with floating thrombosis of the left ventricular aneurysm and complete atrioventricular block infected with a COVID-19: a case report

Left ventricular (LV) thrombosis is a common complication of heart failure with reduced LV ejection fraction and can be a source of systemic embolism. The material presents the case of a 76-year-old woman with a history of myocardial infarction, LV aneurysm, coronary bypass surgery, who was admitted to the hospital with ischemic vertebrobasilar stroke. One month prior to present hospitalization, the patient was admitted to the hospital with transient complete atrioventricular block, underwent coronary artery stenting for stable angina pectoris with a drug-eluting stent, and was subsequently diagnosed with coronavirus disease 2019 (COVID-19), which required further inpatient treatment. Despite dual antithrombotic therapy (antiplatelet+anticoagulant) taken after discharge from the hospital, the patient was diagnosed with a floating thrombus in the apical LV aneurysm. Recurrent conduction disorders (transient atrioventricular block) required temporary pacing until the thrombus elements floated, after which a dual-chamber pacemaker was implanted. The main feature of this case is the formation of a floating thrombus in the LV aneurysm 11 years after myocardial infarction against the background of COVID-19 and anticoagulant therapy with direct oral anticoagulants. At the moment, there is still no unique opinion on the choice of anticoagulant therapy in patients with COVID-19 and a complicated cardiovascular history. In such cases, the anticoagulant regimen should be determined by a multidisciplinary team, taking into account the risks of thrombosis and bleeding.

Abstract Number ‐ 170: Trends for Endovascular Mechanical Thrombectomy versus Intravenous Tissue Plasminogen Activator for Vertebrobasilar Stroke Treatment

Introduction Acute vertebrobasilar artery occlusion (VBAO) represents approximately 20% of patients presenting with acute ischemic stroke. The occlusion is caused by an embolus or underlying atherosclerotic disease plaque rupture forming an acute thrombus. Without treatment, VBAO’s mortality nears 80–90%, thus, effective and timely treatment strategies become paramount in managing the patients. Herein, we analyzed the age difference and outcomes in patients that underwent either Endovascular Mechanical Thrombectomy (MT) or intravenous (IV) tissue plasminogen activator (tPA). Methods National Inpatient Sample (NIS) was queried from years 2016 to 2018 using ICD‐10 diagnosis and procedure codes for occlusion or thrombosis of vertebral artery or basilar artery (I63.21, I63.22, I63.01, and I63.02), IV tPA (3E03317), and MT (03CG3ZZ, 03CG3Z6, 03CG3Z7, 03CG4Z6, 03CG4ZZ). Chi‐square test and was used for statistical analysis. Results From 2016 to 2018, there were 37,310 patients admitted with vertebrobasilar stroke. Out of these, IV tPA was administered in 2,530 (6.8%) admissions, whereas MT was done in 2,330 (6.2%) admissions. IV tPA was used significantly more than MT in age groups 65–84 and &gt; = 85 years. MT was used significantly more than IV tPA in age groups 18–44 and 45–64 (Figure 1). There was no significant difference in their use between men and women. In large hospitals, MT was more common than IV tPA (8.1% vs 7%, p &lt; 0.0001), and in small hospitals, IV tPA usage was significantly higher (3.8% vs 2%, p &lt; 0.0001). All‐cause mortality rate was significantly higher in MT than IV tPA admissions (16.8% vs 8.1%, p &lt; 0.0001). There was no significant difference in mean length of stay (LOS) between the two modalities (Figure 1). Conclusions We saw a trend of higher rate of mechcnical thrombectomy in younger age group (18‐64 years) than older, however, no sex difference was noted. All‐cause mortality rate was higher in the mechanical thrombectomy group than intravenous tissue plasminogen activator group. In addition, there was no difference in length of hospital stay.

Abstract Number ‐ 86: Intracranial Angioplasty via Type II Proatlantal Intersegmental Artery

Introduction A proatlantal intersegmental artery (PIA) is an exceedingly rare primitive anastomosis between the carotid and vertebrobasilar circulations. PIA’s may be accompanied by ipsilateral or bilateral vertebral artery (VA) agenesis and can originate from the cervical internal carotid artery (ICA, type I) or external carotid artery (ECA, type II) before eventually joining the vertebrobasilar system. Several authors have described this anomaly in different clinical scenarios, but to our knowledge, there are no studies documenting intracranial vertebral artery angioplasty through a type II PIA in the setting of a vertebrobasilar stroke. Methods Single case study Results A 62‐year‐old male presented to the ED with slurred speech that began one hour prior to arrival. Computer tomography (CT) of the head revealed a small right posterior acute parietal subdural hematoma, and CT perfusion scan revealed ischemia of the cerebellar hemispheres bilaterally with small areas of core infarction and a moderate‐to‐large surrounding penumbra. Magnetic resonance imaging (MRI) of the brain was positive for bilateral acute ischemic strokes of the cerebellar and pontine arteries. CT angiogram of the head and neck revealed high grade stenosis of the right intracranial VA and narrowing of the left V1, V2, and V3 segments. The proximal left V4 segment was occluded with distal reconstitution. Catheter angiogram of the ICAs and ECAs showed that the patient’s right VA did not originate from the right subclavian artery but instead from the right ECA. The patient was subsequently determined to have a type II PIA with critical stenosis. We proceeded with right VA submaximal angioplasty via the type II PIA. The procedure went without complications and resulted in restoration of vertebrobasilar blood flow, with only moderate stenosis following the submaximal angioplasty. On day 5 postoperatively, the patient reported resolution of his symptoms and was subsequently discharged. Conclusions We presented a case of vertebrobasilar stroke in which the right VA did not originate from the right subclavian artery but instead from the ECA, with a subsequent diagnosis of a type II PIA. The only option for management was to perform the right VA angioplasty via the PIA, which we believe to be the first documented case of intracranial vertebral angioplasty through a type II PIA. This case serves as a reminder of the very rare cases of persistent fetal circulation and the importance of performing a catheter angiogram of both the ICA and ECA. Evaluation of the ECA and subsequent observation of a PIA can completely change both the management and outcomes of the patient. This case underscores the complexity of the intracranial atherosclerotic disease, the beneficial role of endovascular intervention, and the necessity of future studies to identify the optimal treatment methods for vertebrobasilar stroke.

Study of Incidence of Ponticulus Posterior In Dry Human Atlas Vertebra and Its Clinical Significance

Background: Atlas is the first cervical vertebra. The vertebral artery lies in the groove on posterior arch of the atlas. The vertebral artery groove may sometimes get converted into a foramen. This is commonly known as ponticulus posterior (ponticulus posticus) or arcuate foramen of the atlas. These foramina may be complete or incomplete. This can lead to compression of the vertebral artery and produce symptoms like headache, syncope, altered consciousness etc. It can also complicate manipulations of the cervical spine by reducing the blood flow during extreme rotations of head and neck. It is also associated with vertebrobasilar artery stroke So, neurosurgeons or orthopaedic surgeons who operate in this area should have a detailed knowledge of variations of groove for the vertebral artery. Materials and Methods: The present study was conducted on 50 dried and fully ossified adult human atlas of unknown age and sex collected from the department of Anatomy, Government Medical college, Nagpur. Each atlas vertebra was carefully observed for the presence or absence of complete or incomplete ponticuli on superior surface of posterior arch of atlas. Results: Out of the 50 vertebra studied 7(14%) showed the presence of Ponticuli. Ponticuli were incomplete in all 7 atlas vertebras. Complete ring was not observed in any of the atlas vertebra .Out of the 7 ponticuli 6(12%) were found to be unilateral and in only 1 (2%) case it was found to be bilateral. Out of the 6 ponticuli 4(8%) were noticed on the Left side and 2(4%) were present on the right side. Conclusion: Presence of incomplete ponticulus posterior might cause cervical pain and even cerebrovascular disorders due to pressure on third part of vertebral artery present in the vertebral artery groove. This anatomical knowledge is important for neurosurgeons, orthopaedic surgeons, radiologists and clinicians while dealing with this region. KEYWORDS: Ponticulus Posterior, Atlas, Cervical Vertebra, Cerebrovascular disorders, Vertebral artery.