Vertebrobasilar Stroke Research Articles

Vertebral Artery Dissection Following Anterior Cervical Decompression and Artificial Disc Replacement

Vertebral artery dissection (VAD) is a rare vascular cause of acute stroke. Although VAD may be classified as spontaneous or traumatic, it is increasingly recognized that trivial mechanical stress typically precipitates this potentially dangerous condition. Herein, we report a rare case of VAD and acute stroke following anterior cervical decompression and artificial disc replacement (ADR). To our knowledge, there have been no other cases of acute vertebrobasilar stroke caused by VAD following anterior cervical decompression and ADR. This case highlights that, although rare, acute vertebrobasilar stroke may occur after the anterior cervical approach.

General anesthesia vs. non-general anesthesia for vertebrobasilar stroke endovascular therapy.

The optimal type of anesthesia for acute vertebrobasilar artery occlusion (VBAO) remains controversial. We aimed to assess the influence of anesthetic management on the outcomes in VBAO patients received endovascular treatment (EVT). Patients underwent EVT for acute VBAO at 21 stroke centers in China were retrospectively enrolled and compared between the general anesthesia (GA) group and non-GA group. The primary outcome was the favorable outcome, defined as a modified Rankin Scale (mRS) score 0-3 at 90 days. Secondary outcomes included functional independence (90-day mRS score 0-2), and the rate of successful reperfusion. The safety outcomes included all-cause mortality at 90 days, the occurrence of any procedural complication, and the rate of symptomatic intracranial hemorrhage (sICH). In addition, we performed analyses of the outcomes in subgroups that were defined by Glasgow Coma Scale (GCS) score (≤8 or >8). In the propensity score matched cohort, there were no difference in the primary outcome, secondary outcomes and safety outcomes between the two groups. Among patients with a GCS score of 8 or less, the proportion of successful reperfusion was significantly higher in the GA group than the non-GA group (aOR, 3.57, 95% CI 1.06-12.50, p = 0.04). In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar results were found. Patients placed under GA during EVT for VBAO appear to be as effective and safe as non-GA. Furthermore, GA might yield better successful reperfusion for worse presenting GCS score (≤8). URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.

Abstract WMP79: Stroke Risk Prediction In Symptomatic Anterior Circulation ICAS: Post Hoc Analysis Of Regional QMRA Flow From The MYRIAD Study

Introduction: Intracranial atherosclerotic disease (ICAD) remains a major source of stroke worldwide, with high recurrence risk. Prior evaluation of posterior circulation ICAD patients enrolled in the prospective VERiTAS and MYRIAD studies revealed regional hypoperfusion, assessed by large vessel flow measurements using quantitative MRA (QMRA), predicts subsequent vertebrobasilar stroke risk. We examined whether a similar approach to regional flow assessment using QMRA predicted stroke risk in anterior circulation ICAD patients enrolled in MYRIAD. Methods: MYRIAD enrolled patients with recent TIA or stroke attributable to 50-99% stenosis of proximal intracranial artery; the primary outcome was ischemic stroke in the territory of the stenotic artery with 1 year of follow-up. Secondary outcomes included new in-territory infarcts on MRI at 6-8 weeks. Flow was measured in the major intracranial arteries at baseline using QMRA. We designated patients as low- or normal-flow status based on an algorithm assessing distal flow and collateral capacity using age-normalized MCA and hemispheric (aggregate of ipsilateral ACA, MCA, and PCA) flows. Different thresholds for flow status categorization were tested to determine the optimal algorithm for stroke risk prediction. Results: Of 73 enrolled subjects with symptomatic anterior circulation ICAD, 7 (9.6%) patients had recurrent stroke. Z-score thresholds for age-normalized flow ranging from -0.5 to -1.5 were examined. The optimal thresholds identified were as follows: -1 for the MCA and -0.75 for hemispheric flow. 24 (33%) patients were categorized as low-flow status based on these thresholds; recurrent stroke occurred in 21% of low-flow patients vs. 4% of normal-flow patients (OR 6.2 (95% CI 1.1-34.7, p=0.04). However, flow status was not predictive of recurrent infarct on imaging among 61 patients with 6-8 week MRI (32% in low-flow vs. 26% in normal-flow patients). Conclusions: Similar to the predictive value in the posterior circulation, distal flow status assessed through QMRA regional flow measurement appears to be predictive for recurrent clinical (but not imaging-based) stroke. Identification of high-risk patients has implications for future investigation of therapeutic interventions.

The prevalence and clinical significance of intracranial vertebral artery terminated in posterior inferior cerebellar artery: A multicenter hospital-based study in China.

Intracranial vertebral artery terminated in the posterior inferior cerebellar artery (PICA-VA) is the most popular variant of the posterior inferior cerebellar artery, while its prevalence and clinical significance remained unclear. In the present study, we aimed to investigate the prevalence and clinical significance of PICA-VA. This was a multicenter hospital-based cross-sectional study. Patients were enrolled for cerebral MRI and MRA within 1 week of stroke onset. Clinical characteristics were recorded. PICA-VA is termed as a vertebral artery that does not communicate with the basilar artery but terminates in an ipsilateral PICA. We observed the prevalence of PICA-VA and identified a relationship between PICA-VA and vertebrobasilar stroke. From 1 August 2015 to 31 May 2017, a total of 2,528 patients were enrolled in the present study. Among them, 95 patients (3.76%, 95/2,528) had the variation of PICA-VA, 51 of which (53.7%) were located on the right side. The prevalence of vertebrobasilar stroke was considerably higher in patients with PICA-VA than those without (40.2%, 37/92 vs. 17.1%, 417/2,436, p < 0.01). PICA-VA was an independent risk for vertebrobasilar stroke after being adjusted for a history of intracranial hemorrhage, diabetes, body mass index, and triglyceride. The present study showed that 3.76% of patients with acute stroke had PICA-VA, which independently increased the risk of acute vertebrobasilar stroke.

Vertigo in Acute Stroke Is a Predictor of Brain Location but Is Not Related to Early Outcome: The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry.

Vertigo is an uncommon symptom among acute stroke victims. Knowledge about the clinical profile, the brain location, and the early outcome in stroke patients with cerebrovascular diseases and vertigo remains limited. In this study, the effects of vertigo on cerebral topography and early prognosis in cerebrovascular diseases were investigated. A comparative analysis in terms of demographics, risk factors, clinical characteristics, stroke subtypes, cerebral and vascular topography, and early outcome was performed between patients with presence or absence of vertigo on a sample of 3743 consecutive acute stroke patients available from a 24-year ongoing single-center hospital-based stroke registry. Vertigo was present in 147 patients (3.9%). Multiple logistic regression analysis showed that variables independently associated with vertigo were: location in the cerebellum (OR 5.59, CI 95% 3.24-9.64), nausea or vomiting (OR 4.48, CI 95% 2.95-6.82), medulla (OR 2.87, CI 95% 1.31-6.30), pons (OR 2.39, CI 95% 1.26-4.51), basilar artery (OR 2.36, CI 95% 1.33-4.17), ataxia (OR 2.33, CI 95% 1.41-3.85), and headache (OR 2.31, CI 95% 1.53-3.49). The study confirmed that the presence of vertigo was not related with increased in-hospital mortality or poor prognosis at hospital discharge. Vertigo is mainly related to non-lacunar vertebrobasilar stroke with topographic localization in the cerebellum and/or brainstem.

Differential diagnosis of stroke and vestibular neuritis in emergency neurology

Introduction. The differential diagnosis of vertebrobasilar stroke (VBS) and vestibular neuritis (VN) is important challenge for a neurologist when a patient presents to the emergency department with acute vertigo. Current approaches and algorithms of management need to be modified, taking into account clinical practice.&#x0D; The aim of the study was to identify the clinical features of acute vestibular syndrome that are the most helpful in the differential diagnosis of VBS and VN.&#x0D; Materials and methods. We examined 80 emergency admissions to the neurological ward with suspected stroke. A detailed otoneurological examination (including the STANDING and HINTS+ algorithms) and brain imaging (DWI MRI) were performed.&#x0D; Results. Out of 80 patients, 26 were diagnosed with VBS, 30 with VN, 11 with vestibular migraine and 2 with Meniere's disease, while the cause of vertigo could not be determined in 11 patients. The most powerful indicator of VBS in the differential diagnosis was gaze-evoked nystagmus, which had a 15.9-fold association with VBS. An increased likelihood of VBS was also associated with unsteadiness (6.3 times), age over 58 years (4.1 times), dysmetria in the finger-to-nose test (3.7 times), adiadochokinesia (3.1 times), and trunk ataxia (3 times). An increased likelihood of VN was associated with a positive unilateral head impulse test (6 times), nystagmus that followed Alexander's law (3.7 times), and presence of nausea (2.5 times). A model was developed for the differential diagnosis of VBS and VNin patients presenting with acute vertigo. The model accuracy was 100% in the validation sample.&#x0D; Conclusions. Clinical approach remains crucial when differentiating between VBS and VN. The most useful criteria for a differential diagnosis in emergency neurology were the patient's age, the type of nystagmus, head impulse test, and cerebellar dysfunction.

Weber syndrome – clinical-imaging correlations

An 89 years-old female patient was brought in by the family for altered mental status and left-sided motor deficit. Medical history revealed high blood pressure for which the patient was receiving anti-hypertensive treatment. Upon examination, the patient presented altered mental status, dysarthria, dysphagia, left central facial palsy, ataxic tetraparesis with marked paralysis on the left side, bilateral Babinski signs, right-sided ophthalmoplegia with limitation of gaze in all directions, left-sided skew deviation, limited abduction and upgaze movements of the left eye, and bilateral ptosis (complete on the right side and incomplete on the left side). The clinical picture was thus compatible with a vertebrobasilar stroke. A possible diagnosis of Weber syndrome was suggested, given the left-sided hemiparesis and right-sided ophthalmoplegia. Both head CT and brain MRI confirmed this by demonstrating a right-sided thalamo-mesencephalic subacute ischemic stroke. No cardio-embolic source was identified on cardiac assessment. Consequently, the patient was discharged with antiplatelet therapy, statin and anti-hypertensive treatment. We provide a short review on Weber syndrome, emphasizing the correlations between the clinical pictures and imaging findings.

Outcomes Following Mechanical Thrombectomy in Different Etiological Subtypes of Acute Basilar Artery Occlusion : Stroke Etiology and Outcome after EVT in BAO.

Vertebrobasilar occlusion stroke (VBOS) is innately associated with high morbimortality despite advances in endovascular thrombectomy (EVT). Nonetheless, notable outcome dissimilarities exist between angiographically categorized stroke subtypes. We aim to evaluate potential differences concerning clinical angiographic outcomes among etiological subtypes of VBOS based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. We retrospectively reviewed prospective EVT databases at two tertiary care stroke centers for consecutive patients with VBOS who had preinterventional MRI and underwent EVT from January 2015 to December 2019. We identified three groups: large artery atherosclerosis (LAA), cardioembolic stroke (CES), and embolic stroke of undetermined source (ESUS). The primary endpoints were the rates of poor outcome (identified as 90-day modified Rankin scale score of 3-6) and mortality, while the secondary endpoint included the rates of incomplete reperfusion (identified as modified treatment in cerebral infarction scale mTICI 0-2b), and periprocedural symptomatic intracranial hemorrhage. We evaluated the association between the etiology and clinical angiographic outcomes through stepwise logistic regression analysis. Out of 1823 patients, 139 (91men; median age, 69 (61-76) years) with VBOS were qualified for the final analysis with incidence as follows: LAA (41%, n = 57), CES (35%, n = 48), and ESUS (24%, n = 34). Overall, incomplete reperfusion was realized in 41% (57/139) of the patients, apoor outcome in 65% (90/139), and mortality in 40% (55/139). Longer puncture to reperfusion interval (aOR 1.0182 [95% CI: 1.008-1.029]; p < 0.001) and utilization of combined aspiration-retriever technique (aOR 0.1998 [95% CI: 0.066-0.604]; p = 0.004) were associated with agreater likelihood of incomplete reperfusion (mTICI 0-2b) irrespective of the stroke etiology. After adjustment for confounding factors in the regression analysis, ESUS was an independent predictor of poor outcome (aOR 5.315 [95% CI: 1.646-17.163]; p = 0.005) and mortality (aOR 4.667 [95% CI: 1.883-11.564]; p < 0.001) at 90days following EVT. The functional outcome following EVT for VBOS might depend on stroke etiology. According to our results, ESUS seems to be associated with the worst outcome, which needs further investigation to tailor the appropriate therapeutic plan.

Craniovertebral Junction Anomalies: An Overlooked Cause of 'Posterior Circulation Stroke'.

Vertebral artery dissection (VAD) is a treatable cause of vertebrobasilar ischemic stroke and can be spontaneous or more commonly traumatic. Craniovertebral junction (CVJ) anomalies are a rare and often overlooked cause of VAD. The objective of this study was to study cases where CVJ anomaly presented as posterior circulation infarct and to conduct a relevant literature review. The medical records of seven patients who were managed for posterior circulation infarct associated with CVJ anomaly at our center from January 2009 through August 2013 were reviewed. PubMed and MEDLINE databases were also searched for similar cases, and the published case reports/series were reviewed. Seven patients met our inclusion criteria and were included in the study. The mean age was 17.4 years (range: 10-35 years). All the patients were males. The most common symptoms were headache, vomiting, and gait ataxia. Slurring of speech was seen in one patient. One patient had repeated episodes of gait ataxia with left-sided weakness with complete recovery in between the episodes. One patient presented in unconscious state. Four patients complained of vertigo. The median duration of symptoms was 7 days (range: 3 days-12 months). CVJ anomalies can present as posterior circulation infarct. One must evaluate all patients with posterior circulation stroke, especially young patients, for possible CVJ anomalies. Dynamic lateral cervical spine X-ray is an important tool to diagnose AAD. CVJ anomalies represent a treatable cause of VAD.

Progressive Vertebrobasilar Vasculopathy and Stroke Secondary to Giant Cell Arteritis.

HomeStrokeVol. 53, No. 9Progressive Vertebrobasilar Vasculopathy and Stroke Secondary to Giant Cell Arteritis No AccessCase ReportRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessCase ReportRequest AccessFull TextProgressive Vertebrobasilar Vasculopathy and Stroke Secondary to Giant Cell Arteritis Yasamin Mahjoub, MD, Erica D. McKenzie, MD, Saher Raouf and Mohammed Almekhlafi, MD Yasamin MahjoubYasamin Mahjoub Correspondence to: Yasamin Mahjoub, MD, Foothills Medical Centre, 1403 29 St NW, Calgary, AB T2N 2T9. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0898-3307 Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada. Search for more papers by this author , Erica D. McKenzieErica D. McKenzie https://orcid.org/0000-0003-4369-413X Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada. Search for more papers by this author , Saher RaoufSaher Raouf https://orcid.org/0000-0003-3338-7937 Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada. Search for more papers by this author and Mohammed AlmekhlafiMohammed Almekhlafi https://orcid.org/0000-0001-9550-8197 Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada. Search for more papers by this author Originally published15 Aug 2022https://doi.org/10.1161/STROKEAHA.122.039503Stroke. 2022;53:e435–e438FootnotesCorrespondence to: Yasamin Mahjoub, MD, Foothills Medical Centre, 1403 29 St NW, Calgary, AB T2N 2T9. Email [email protected]ca

Two case reports of successful Endovascular treatment of Vertebrobasilar insufficiency: A Case of an incomplete Balint syndrome and recurrent Vertebrobasilar stroke

Two case reports of successful Endovascular treatment of Vertebrobasilar insufficiency: A Case of an incomplete Balint syndrome and recurrent Vertebrobasilar stroke

Repeated Vertebrobasilar Strokes Caused by Varicella Zoster Virus Vasculopathy.

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Clinical Features Differ Between Patients With Vertigo Attack Only and Weakness Attack Accompanying Vertigo Before Vertebrobasilar Stroke: A Retrospective Study.

ObjectiveTo determine the different clinical features of patients with vertigo attacks alone and of those with weakness accompanying vertigo attacks before the vertebrobasilar ischemic stroke.MethodsIn this 4-year retrospective study, we manually screened the medical records of 209 patients, hospitalized with vertigo attack as the main complaint who were finally diagnosed with acute vertebrobasilar ischemic stroke. Patients were divided into two groups according to their symptoms: patients who only experienced vertigo attacks prior to the vertebrobasilar stroke (VO group) and patients who had both vertigo and weakness attacks (VW group) prior to the stroke. Clinical parameters, such as infarction site and volume, relative risk factors, ABCD2 score, and medical intervention, were compared between the two groups.ResultsThe prevalence of hypertension was higher in the Vertigo attacks only (VO) group (42.2 vs. 29.0%, p < 0.05). The total cerebral infarction volume in the VO group was larger than the Vertigo and weakness attacks (VW) group (4.44 vs. 2.12 cm3, p < 0.05). Additionally, the cerebellum was more likely to be affected in the VO group. In contrast, patients in the VW group had higher carotid stenosis (14.2 vs. 27.2%, p < 0.05) and ABCD2 score (2.1 ± 1.2 vs. 3.6 ± 1.5, p = 0.02). The percentage of patients with medullary infarctions also increased in the VW group. Vertigo attack events occurred more frequently in the VW group (median 2.4 vs. 4.3, p < 0.04). We also found that the patients in the VW group were more likely to seek medical intervention after vertigo.ConclusionsClinical parameters, such as infarction location, relative risk factors, and ABCD2 score, differed between patients with vertigo symptoms with or without weakness attacks. These findings highlight the different clinical features of patients with vertigo attack only and those with weakness attacks accompanying vertigo prior to vertebrobasilar ischemic stroke.

Machine Learning–Based Identification of Target Groups for Thrombectomy in Acute Stroke

Whether endovascular thrombectomy (EVT) improves functional outcome in patients with large-vessel occlusion (LVO) stroke that do not comply with inclusion criteria of randomized controlled trials (RCTs) but that are considered for EVT in clinical practice is uncertain. We aimed to systematically identify patients with LVO stroke underrepresented in RCTs who might benefit from EVT. Following the premises that (i) patients without reperfusion after EVT represent a non-treated control group and (ii) the level of reperfusion affects outcome in patients with benefit from EVT but not in patients without treatment benefit, we systematically assessed the importance of reperfusion level on functional outcome prediction using machine learning in patients with LVO stroke treated with EVT in clinical practice (N = 5235, German-Stroke-Registry) and in patients treated with EVT or best medical management from RCTs (N = 1488, Virtual-International-Stroke-Trials-Archive). The importance of reperfusion level on outcome prediction in an RCT-like real-world cohort equaled the importance of EVT treatment allocation for outcome prediction in RCT data and was higher compared to an unselected real-world population. The importance of reperfusion level was magnified in patient groups underrepresented in RCTs, including patients with lower NIHSS scores (0–10), M2 occlusions, and lower ASPECTS (0–5 and 6–8). Reperfusion level was equally important in patients with vertebrobasilar as with anterior LVO stroke. The importance of reperfusion level for outcome prediction identifies patient target groups who likely benefit from EVT, including vertebrobasilar stroke patients and among patients underrepresented in RCT patients with low NIHSS scores, low ASPECTS, and M2 occlusions.

Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks.

Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.

Vertebrobasilar Stroke: Association Between Infarction Patterns and Quantitative Magnetic Resonance Angiography Flow State.

BackgroundTreatment and prognosis of vertebrobasilar atherosclerotic disease differs depending on stroke mechanism, such as artery‐to‐artery embolism, branch atheromatous disease, and hemodynamic ischemia. Our aim was to investigate the relationship between infarction pattern and flow status using quantitative magnetic resonance angiography (QMRA), to determine the validity of using infarction patterns to infer stroke mechanism.Methods and ResultsThis is a retrospective study of patients with ischemic stroke with intra‐ or extracranial vertebrobasilar atherosclerotic stenosis, who underwent magnetic resonance imaging of the brain, neurovascular imaging, and QMRA, between 2009 and 2021. Patients with cerebral infarction predating or following QMRA by ≥1 year, or QMRA studies performed for basilar thrombosis, vertebral dissection, or only postangioplasty/stenting, were excluded. Poststenotic flow (basilar and posterior cerebral arteries) was dichotomized as low‐flow or normal‐flow based on published criteria. Of 1211 consecutive patients who underwent QMRA noninvasive optimal analysis, 69 met inclusion. Mixed patterns were most common (46.4%), followed by perforator (23.2%), borderzone (14.5%), and territorial (15.9%). Patients with low‐flow had a significantly higher rate of borderzone+ patterns (borderzone alone or in mixed pattern) compared with patients with normal‐flow (77.4% low‐flow versus 39.5% normal‐flow, P=0.002). Borderzone+ patterns were associated with 61.5% probability of low‐flow state, while no borderzone (perforator/territorial) patterns were associated with 76.7% probability of normal‐flow state.ConclusionsBorderzone infarction pattern (alone or mixed) was associated with low poststenotic posterior circulation flow by QMRA. However, borderzone pattern only moderately predicted low‐flow state, and may be an unreliable flow marker. Therefore, infarct topography may complement, but should not replace hemodynamic studies to establish flow status.

Abstract TMP31: Genesis Of Malpractice Risk With Mechanical Thrombectomy

Introduction: In 1996 tPA was approved for treatment of acute ischemic stroke (AIS), leading to a higher bar for quality of care but also to many medical-legal claims. Subsequent reviews of legal databases showed most lawsuits were for failure to treat rather than for tPA-associated complications. Acute stroke care has again undergone a paradigm shift with the landmark mechanical thrombectomy (MT) trials, the AHA’s recommendation of MT for AIS, and its adoption as standard of care therapy for acute large vessel occlusions of the brain in select patients. Accordingly, lawsuits have been brought forward alleging malpractice. The aim of our study was to systematically review legal databases to better understand claims pertaining to MT. Methods: Legal databases were searched using key words “stroke” and “thrombectomy”. Cases were included if they were medical malpractice claims for AIS involving endovascular MT. Cases with and without verdicts were included and were systematically categorized based on claims and case details including vascular territory, interventions, and plaintiff/defendant arguments. Results: Search criteria revealed 313 results of which 25 cases met inclusion criteria. Cases were most frequently excluded due to duplicate result (n=126), or not being a malpractice claim for AIS (n=65). Anterior circulation strokes were the cause of complaint in 13 cases, vertebrobasilar and related strokes in 10 cases, and other/unknown in 2 cases. In 16 cases MT was not performed, leading to an alleged failure to timely diagnose and treat AIS. In the remaining 9 cases where MT was performed, 8 cases also alleged failure of timely treatment and 1 claimed complications of MT. Other frequent allegations included failure of timely consultation, performance of vascular imaging, or transfer. Specific allegations related to delay in transfer included choice of road vs. air ambulance travel, and transfer to in-network hospital vs. nearest MT-capable center. One case involved a tele-stroke neurologist. Conclusions: Similar to medical-legal claims for tPA, failure to perform (or failure to timely perform) MT was a common complaint. In addition, delays in obtaining vascular imaging and logistical delays in transfer causing potential delays in MT were commonly noted.

The Impact of Time to Reperfusion on Recanalization Rates and Outcome After Mechanical Thrombectomy: A Single Center Experience.

Background:Timely and effective recanalization to salvage the penumbra is the main determinant of outcome in acute ischemic strokes. Randomized controlled trials on late window mechanical thrombectomy (MT) have proved its safety and efficacy upto 24 h after stroke onset. We looked at the impact of time to reperfusion on vessel recanalization rates and short-term outcome in patients undergoing MT for large vessel occlusion.Methods:The clinical, imaging, and outcome of all patients undergoing MT upto 24 h from last seen normal was extracted from a prospectively maintained ischemic stroke database from January 2012 till September 2019.Results:There were 145 patients with a mean (SD) age of 58.2 (±14) years. Of them, 28 had wake up/unknown time of onset stroke and 9 presented beyond >360 min. There were 23 vertebrobasilar strokes. Median National Institute of Health Stroke scale score (NIHSS) at admission was 16.4 (Inter quartile range (IQR) 12–21). CT-Alberta Stroke program early CT score (CT-ASPECTS) was excellent (8–10) in 39 (31.6%) and fair (5–7) in 77 (63.6%) patients in anterior circulation strokes. About 25% underwent bridging therapy. Recanalization rates did not differ between those presenting early (<6 h) versus wake up strokes and late presenting patients (81.79% vs 71.9%). Symptomatic Intracerebral hemorrhage (ICH) occurred in 5%. At 3 months, excellent outcome (modified rankin scale <2) was observed in 28.9%. While Admission NIHSS remained strong predictor of poor outcome at 3 months, delay in presentation did not impact MT outcome (37.5% vs 45.79% and P = 0.460).Conclusions:The recanalization rates were similar in patients irrespective of the time to reperfusion from stroke onset. The functional outcome was not inferior in late presenters selected by advanced imaging.

Laser analyzer as an objective method for evaluating walking parameters in patients with post-stroke disorders

To estimate the informativity, sensitivity and specificity of the method of assessing gait function in patients with ataxia and post-stroke hemiparesis using the LA-1 «Laser Analyzer of Kinematic Gait Parameters». Main tempo-rhythm and spatial gait parameters were assessed in groups of healthy people of young (n=30) and middle (n=30) age. At the second stage, the gait parameters of healthy people were compared with those of patients with ataxia due to vertebrobasilar stroke (n=30) and with post-stroke hemiparesis (n=30). The following parameters were evaluated: the average length and duration of step, the standard deviation of step length, the standard deviation of step duration, coefficient of variability for step length & duration. The high sensitivity and specificity of the method were established. Standard values were determined for all indicators in groups of healthy people and statistically significant features of the main gait parameters for these syndromes were identified. There were an increase in the step length and duration, standard deviation of step length and duration, step variability coefficients, and a decrease in walking speed. Conclusion. The results are in line with those of earlier studies on the gait change in patients with post-stroke disorders. The LA-1 method can be recommended for clinical use.

A Narrative Review of Contemporary Global Perspectives into Epidemiology, Treatment, and Prognosis of Vertebrobasilar Strokes

Blood flow interruptions to the posterior cerebral circulation hallmark vertebrobasilar strokes (VBS), leading to mortality and significant disabilities, yet optimal therapy prevails unpublished. Recent epidemiological evidence indicates that VBS account for nearly 1/5 of all ischemic strokes globally, with acute basilar artery occlusion (BAO) contributing significant disabilities in nearly 1/3 of the victims. The prevalence of VBS in Africa is close to 5%, majorly in large intracranial vessels. Etiologically, Stenosis accounts for 20% of all VBS, while aneurysms face up to a 3% rupture rate. Furthermore, intravenous alteplase is the gold standard medical therapy for the cases presenting within 3 to 4.5 hours post-baseline regarding management options. Nevertheless, there is no consensus for BAO beyond 4.5 hours post-onset. Stent retrievers are the first-line endovascular reperfusion therapy device proposed. However, an 18% risk of in-stent restenosis is a significant drawback. Comprehensive prognostic factors are addressed in this review. However, prospective, multicenter, controlled studies are needed to clarify the time window dilemmas facing posterior circulation strokes. This narrative review explores recent VBS epidemiology, management advances, and prognosis.Rwanda J Med Health Sci 2021;4(3):418-429