Intrinsic stenosing and occlusive pathologies of the vertebral artery: A narrative review.

Intrinsic pathologies of the vertebral arteries, such as atherosclerosis, dissection, fibromuscular dysplasia, radionecrosis and vasculitis, are important causes of vertebrobasilar insufficiency and cerebrovascular events. This review focuses on non-aneurysmal intrinsic stenosing and occlusive pathologies, covering their epidemiology, diagnosis, and treatment options. It also provides a detailed summary of key clinical presentations and syndromes, including an in-depth examination of lateral medullary syndrome, historically known as Wallenberg's syndrome, which is arguably the most emblematic condition resulting from vertebral artery involvement and is depicted in an illustrative cartoon.

Preconditioning by Preceding Ischemic Cerebrovascular Events.

Background Emerging yet contrasting evidence from animal and human studies associates ischemic preconditioning with improvement of subsequent stroke severity, although long-term outcome remains unclear. The purpose of this study was to analyze how preceding cerebral ischemic events influence subsequent stroke severity and outcome. Methods and Results Data for this retrospective cohort study were extracted from ASTRAL (Acute Stroke Registry and Analysis of Lausanne). This registry includes a sample of all consecutive patients with acute ischemic strokes admitted to the stroke unit and/or intensive care unit of the Lausanne University Hospital, Switzerland. We investigated associations between preceding ischemic events (transient ischemic attacks or ischemic strokes) and the impact on subsequent stroke severity and clinical improvement within 24 hours, measured through National Institute of Health Stroke Scale, as well as 3-month outcome, determined through a shift in the modified Rankin Scale. Of 3530 consecutive patients with ischemic stroke (43% women, median age 73 years), 1001 (28%) had ≥1 preceding cerebral ischemic events (45% transient ischemic attack, 55% ischemic stroke; 31% multiple events). After adjusting for multiple prehospital, clinical, and laboratory confounders, admission stroke severity was significantly lower in patients preconditioned through a preceding ischemic event, but 24-hour improvement was not significant and 3-month outcome was unfavorable. Conclusions Preceding ischemic events were independently associated with a significant reduction in subsequent stroke severity but worsened long-term clinical outcome. These results, if confirmed by future randomized studies, may help design neuroprotective strategies. The unfavorable effect on stroke outcome is probably a consequence of the cumulative disability burden after multiple ischemic events.

Factors Associated With Focal Computed Tomographic Perfusion Abnormalities in Supratentorial Transient Ischemic Attacks.

BACKGROUND AND PURPOSE: Computed tomographic perfusion (CTP) is useful in diagnosis of patients with transient focal neurological symptoms. In acute imaging of patients with a suspected transient ischemic attack (TIA), it remains unclear which patients develop focal perfusion abnormalities (FPA), that is, hypoperfusion or hyperperfusion. We aimed at determining independent factors associated with FPA in patients with supratentorial TIAs. METHODS: We prospectively collected consecutive patients with supratentorial TIAs defined by the traditional time-based definition who underwent CTP within 24 hours of symptom onset. We recorded demographics, risk factors, clinical features, severity, and timing from onset. We documented the Age, Blood Pressure, Clinical Features, Duration, and Diabetes (ABCD2) scores, vascular territories, and presence of relevant arterial pathology. Variables were tested for an association with FPA with univariate and multivariate analyses. RESULTS: A hundred and ten of 265 patients (42%) with supratentorial TIAs had FPA on CTP. Acute noncontrast computed tomography showed early ischemic lesions in 6%, and acute/subacute magnetic resonance imaging was pathological in 52 of the 109 cases (47.7%) where it was performed. Clinical factors associated with FPA were high-admission National Institutes of Health Stroke Scale (odds ratio [OR], 1.22), right hemispheric TIA (OR, 3.09), and cardioembolic mechanism (OR, 2.19). Persistence of symptoms during CTP (OR, 2.59), shorter duration of TIA (OR, 0.93), major intracranial arterial pathology (OR, 12.5), and extracranial arterial occlusion (OR, 7.44) were also associated with FPA. CONCLUSIONS: Supratentorial TIAs are often associated with FPA in CTP, even after symptom resolution. FPAs are frequent in severe TIAs and those associated with cardioembolism or specific arterial pathologies. These findings can help clinicians in accurate diagnosis of TIA and its underlying mechanisms.

Beauty parlor stroke revisited: An 11-year single-center consecutive series.

BACKGROUND: Hairdresser-related ischemic cerebrovascular events (HICE) are attributed to compression of vertebral arteries or cervical artery dissections. We determined their frequency, mechanisms, localization and outcome in a pre-specified study. METHODS: We prospectively collected ischemic strokes and transient ischemic attacks occurring in relation to a hairdresser visit from 2002 to 2013, using consecutive data from an ischemic stroke registry (ASTRAL). HICE were compared to all other acute ischemic strokes in ASTRAL. RESULTS: We identified 10 HICE (9 strokes and 1 transient ischemic attack). Age and anterior-posterior distribution were similar with a significantly higher rate of females (90% vs. 43%, p = 0.02) in the HICE group compared to ASTRAL. Patients with HICE had significantly lower incidence of hyperlipidemia (30% vs. 73%) and diabetes (0% vs. 19%). The mechanisms of HICE were diverse: carotid artery dissection (n = 2), cardiac (n = 2), lacunar (n = 2), other determined (n = 2) and unknown etiology (n = 2). Two HICE with atherosclerotic intracranial disease were possibly caused by acute hemodynamic changes related to systemic hypotension during hot air hair drying. Unadjusted favorable outcome at three months seemed to be better in HICE (90% vs. 57%), and 12-month mortality and recurrences were similar. CONCLUSIONS: HICE may occur frequently in females without a predilection for the posterior circulation. Although some HICE may occur by chance (pseudo-HICE), hairdresser visits may have a causal role in some cases, including cervical artery dissection or hemodynamic compromise related to pre-existing arterial disease (true HICE). Available data are insufficient for specific preventive recommendations.