Endovascular Recanalization for Nonacute Intracranial Vertebral Artery Occlusion According to a New Classification.

BACKGROUND AND PURPOSE: Endovascular recanalization for patients with nonacute intracranial vertebral artery occlusion remains clinically challenging. We aim to evaluate the feasibility and safety of endovascular recanalization for nonacute intracranial vertebral artery occlusion and propose a new angiographic classification. METHODS: Fifty patients with symptomatic atherosclerotic nonacute intracranial vertebral artery occlusion from January 2015 to December 2019 were analyzed, retrospectively. The rate of recanalization, peri-procedural complications, and follow-up results were evaluated. All patients were divided into 4 groups according to an angiographic classification. RESULTS: Among the 50 patients, 38 (76%) achieved successful recanalization. Any stroke or death within 30 days was 4% (2/50). From type I to type IV, the recanalization rate gradually decreased (94.1%, 76.9%, 70%, and 50%, respectively, P=0.012), while the perioperative complication rate gradually increased (0.0%, 7.7%, 20%, and 50%, respectively, P=0.001). CONCLUSIONS: Endovascular recanalization may be feasible and safe for carefully selected patients with symptomatic atherosclerotic nonacute intracranial vertebral artery occlusion and, therefore, represents an alternative treatment, especially for type I and type II patients.

Current treatment of basilar artery occlusion.

Basilar artery occlusion (BAO) is associated with high mortality (85-95%) if recanalization does not occur. Evidence of the efficacy of different therapy protocols of intravenous thrombolysis (IVT) or intraarterial thrombolysis (IAT) and/or mechanical endovascular treatment is based on retrospective or prospective patient cohorts, since randomized controlled trials (RCTs) do not exist. Roughly a third of BAO patients reach independent outcome following thrombolysis. From those in whom recanalization occurs, about half will reach independence. In noninvasive and endovascular protocols, recanalization of BAO is reached in 60-85% of the patients. While invasive endovascular approaches afford greater recanalization rates, they have not been proven superior to IVT in terms of functional outcome. Meaningful survival after BAO requires rapid access to thrombolysis. "Bridging" protocols have been introduced where rescue therapies such as endovascular thrombolysis and on-demand mechanical thrombectomy or angioplasty are used. Multimodal imaging techniques should be used to choose the best therapeutic option individually.

Transcranial Doppler grading criteria for basilar artery vasospasm.

OBJECTIVE: Transcranial Doppler (TCD) criteria for basilar artery (BA) vasospasm are poorly defined, and grading criteria for vertebrobasilar vasospasm are unavailable. The purpose of the present study was to define TCD grading criteria for BA vasospasm on the basis of the absolute flow velocities and the intracranial to extracranial flow velocity ratios for the posterior circulation, and to improve the sensitivity and specificity of TCD for diagnosis of BA vasospasm. METHODS: One hundred twenty-three patients with aneurysmal subarachnoid hemorrhage underwent 144 cerebral arteriograms with views of the BA during the acute phase of vasospasm (Days 3-14 after hemorrhage). BA diameters were measured and compared with diameters obtained from baseline arteriograms. Both BA and extracranial vertebral artery flow velocities were measured by TCD within 4 hours before the arteriogram. RESULTS: The velocity ratio between the BA and the extracranial vertebral arteries (VA) strongly correlated with the degree of BA narrowing (r2 = 0.648; P < 0.0001). A ratio higher than 2.0 was associated with 73% sensitivity and 80% specificity for BA vasospasm. A ratio higher than 2.5 with BA velocity greater than 85 cm/s was associated with 86% sensitivity and 97% specificity for BA narrowing of more than 25%. A BA/VA ratio higher than 3.0 with BA velocities higher than 85 cm/s was associated with 92% sensitivity and 97% specificity for BA narrowing of more than 50%. CONCLUSION: The BA/VA ratio improves the sensitivity and specificity of TCD detection of BA vasospasm. On the basis of the BA/VA ratio and BA mean velocities, we suggest new TCD grading criteria for BA vasospasm.

[The efficiency of magnetic resonance angiography (MRA) in the diagnosis and vertigo--prediction of vertebrobasilar insufficiency (VBI) and atherosclerosis].

Major causes of vertigo in patients who attend Otolaryngology clinics are peripheral vestibular disorders (PVD) and vertebrobasilar insufficiency (VBI). The purpose of this study was to see whether MRA findings can distinguish VBI from PVD to evaluate the efficiency of MRA in the diagnosis of vertigo. A total of 185 vertigo patients were examined by MRA with the 3D-Phase Contrast method. Three kinds of abnormalities of vessels, that is, (a) disappearance, (b) meandering, and (c) stoppage were found in MRA imaging. Therefore, we classified the MRA patterns into four types with two subtypes: type I; normal, type II-R; right hypoform of the vertebral artery, II-L; left hypoform of the vertebral artery, III; meandering form of the vertebrobasilar artery, IV-1; stoppage form of the basilar artery, IV-2; hypoform of the bilateral vertebral and basilar arteries. Diagnosis of the MRA patterns in each patient was camed out by a radiologist and neurosurgeon with the cooperation of an otolaryngologist. In 185 vertigo patients, 139 patients were clinically diagnosed as having PVD, 41 patients as having VBI, and 5 patients as having cerebellar and brainstem infarctions. The numbers of patients in MRA patterns I, II-R, II-L, III and IV were 140, 17, 12, 8, and 8 cases, respectively. The total number of VBI patients who demonstrated type III or IV patterns in MRA was significantly higher than that of type I, II-R and II-L (P < 0.005). All of the 8 cases with cerebellar and brainstem infarction belonged to type IV. Cerebral angiography was performed in nine cases with type II-R, II-L, III or IV-1, and the number of patients in each group was 3, 3, 1 and 2 cases, respectively. All of the type II-R and II-L cases revealed hypoform of the vertebral artery. The appearance of type III was restricted to type III's view was only meandering and type IV-1 showed severe stenotic changes in the union area. These data show that MRA findings in the diagnosis of vertigo patients are very effective in distinguishing VBI and cerebellar and brainstem infarction from PVD and that some pattern of MRA may correspond to atherosclerosis of the vertebrobasilar artery. We think MRA examination of vertigo patients is useful not only to assist in the diagnosis of the etiology but also to predict the stage of atherosclerosis in each patient.

Vertebrobasilar insufficiency: correlation of clinical and radiologic findings.

Radiological and clinical findings of 20 cases with angiographically proven stenosis or occlusion of the vertebrobasilar system and with clinical signs and symptoms attributable to posterior circulation disorder were studied. A simplified classification of vertebrobasilar arterial disease was presented; type I refers to stenosis of the vertebrobasilar system or subclavian artery, type II refers to vertebrobasilar occlusion, and type III refers to vertebrobasilar branch disease. Type I lesions were further subdivided into types Ia and Ib; type Ia cases showed no infarction in the posterior territory, whereas type Ib cases showed one or more infarctions on computed tomography or magnetic resonance imaging. This angiographic classification is based on treatment options that can be adopted to specific types of lesion. In type I cases, lesions are usually amenable to surgical or angiographic intervention. In type II cases, short-term anticoagulation is the treatment of choice. In type III cases, treatment is primarily aimed at prevention of complication and further stroke.

Types of basilar artery syndrome: clinicoradiologic correlation.

Twenty-two patients with ischemic stroke, as a single event, in the territory of basilar artery (BA) are reported. On the basis of the findings from computerized tomography (CT) and clinico-radiologic features, the authors propose that this heterogeneous entity--the basilar artery (BA) syndrome--can be divided into five subtypes. Type 1 (complete type), characterized by infarctions in the whole territory of BA, is incompatible with life; type 2, with extensive brain stem infarct, may result in a locked-in state; and type 3, with infarctions in part of the BA territory (incomplete form or "partial syndrome") may have a more variable clinical outcome. However, type 4, with a top of the BA syndrome, and type 5, with negative CT BA syndrome (angiographically verified), are often more benign. Although initial CT scanning may infrequently be unrevealing, serial and follow-up CT scannings have proven their usefulness in the majority of cases as a noninvasive tool, in contrast to cerebral angiography, for predicting the short-term prognosis of BA syndrome.

[Vertebrobasilar arterial syndromes]. / Zespoly kregowo-podstawne.

In a group of 60 cases of vertebrobasilar arterial syndromes and 60 cases of hemispheric focal lesions confirmed on autopsy the author analysed early clinical manifestations and the symptoms and signs in the acute period of the disease searching for differences between these syndromes. The statistical analysis showed that circulatory disturbances in the posterior part of the intracranial circulus arteriosus were significantly more frequently associated with occipital headaches, dizziness, equilibrium disturbances, sudden fall of visual acuity and atonic seizures. Apart from this, the author analysed also the early manifestations, symptoms and signs in the acute period of the disease and fully developed clinical picture of the vertebrobasilar arterial syndromes and suggested a tentative clinical classifications of these syndromes according to the location of the lesions in the upper, middle and lower segments of the basilar artery. The author has demonstrated that a careful analysis makes possible isolation of three syndromes: basilar artery trunk syndrome, basilar artery bifurcation syndrome and vertebral artery junction syndrome.