[Repeated ischemic strokes due to infectious arteritis of both internal carotid and basilar arteries as a complication of sphenoiditis and otitis]. / Povtornye ishemicheskie insul'ty pri infektsionnom arteriite obeikh vnutrennikh sonnykh i bazilyarnoi arterii kak oslozhnenie sfenoidita i otita.

The article presents a case of a 54-year-old female patient who, over the course of 2 years, suffered 5 cerebrovascular accidents (CVA) due to infectious arteritis of both internal carotid arteries (ICA) and basilar artery as a complication of sphenoiditis and otitis. According to neuroimaging data, the steno-occlusive process in the ICA developed gradually, starting with the intracranial ICA narrowing with the contrast enhancement by vessel wall, the development of its occlusion six months later, and the detection of the extracranial ICA occlusion with the formation of «flame sign¼ at its mouth a year later. Repeated examination of the cerebrospinal liquid at an early stage of the disease revealed cytosis up to 367/3 and protein 0.66 g/l. The correct diagnosis was established only after 3 years with a retrospective analysis of clinical, neuroimaging, and laboratory data. Therefore, targeted antibiotic therapy was not carried out, which led to the progression of ICA occlusion and repeated strokes. Infectious arteritis should be taken into account in the differential diagnosis of the causes of the ICA occlusive process.

Anatomical differences of the vertebrobasilar artery between normal subjects and patients with cerebral infarction.

Previous studies have reported various anatomical differences in the cerebral artery between healthy subjects and patients with posterior circulation cerebral infarction. In particular, basilar artery angulation has been associated with posterior circulation cerebral infarction. We compared anatomical variations and the degree of anterior and lateral vertebrobasilar artery angulation and deviation to compare the incidence of cerebral infarction of healthy subjects and patients with posterior circulation cerebral infarction. We compared basilar artery anatomy using brain magnetic resonance angiography in 97 patients who underwent brain magnetic resonance angiography during health checkups at our hospital and in 92 patients diagnosed with posterior circulation cerebral infarction between 2012 and 2022. Anatomical variations, including fetal-type posterior cerebral artery, hypoplastic P1 segment, vertebrobasilar dolichoectasia, and dominant vertebral artery, as well as the degree of anterior and lateral deviation and angulation, were evaluated. Correlations between these variations and the occurrence of cerebral infarction were analyzed. The prevalence of hypoplastic P1 was significantly differences in patients with posterior circulation cerebral infarction (odds ratio: 5.655). Furthermore, patients with posterior circulation cerebral infarction exhibited more acute anterior and lateral angulation, as well as lateral deviation. Hypoplastic P1 and more acute anterior or lateral angulation of the vertebrobasilar artery are associated with increased frequency of cerebral infarction.

Transverse diameter of brainstem infarction is a strong predictor of miserable outcome after mechanical thrombectomy for acute basilar artery occlusion.

Although the efficacy of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) has been established in two randomized controlled studies, many patients have miserable clinical outcomes after MT for ABAO. Predicting severe disability prior to the procedure might be useful in determining the appropriateness of treatment interventions. Among the ABAO cases treated at 10 hospitals between July 2014 and December 2021, 144 were included in the study, all of whom underwent MRI before treatment. A miserable outcome was defined as a modified Rankin Scale (mRS) of 5-6 at 3 months. The associations between clinical, imaging, and procedural factors and miserable outcomes were evaluated. A miserable outcome was observed in 54 cases (37.5%). Multivariate analysis identified the National Institutes of Health Stroke Scale (NIHSS), transverse diameter of brainstem infarction, and symptomatic intracerebral hemorrhage as independent factors associated with miserable outcomes, with cutoff values of NIHSS 22 and transverse diameter of brainstem infarction 15 mm. Cases with a higher preoperative severity may result in miserable postoperative outcomes. Particularly, the transverse diameter of a brainstem infarction can be easily measured and serves as a useful criterion for determining treatment indications.

Contrast enhancement boost improves the image quality of CT angiography derived from 80-kVp cerebral CT perfusion data.

RATIONALE AND OBJECTIVE: To investigate the impact of the contrast enhancement boost (CE-boost) technique on the image quality of CT angiography (CTA) derived from 80-kVp cerebral CT perfusion (CTP) data, and to compare it with conventional CTApeak as well as other currently employed methods for enhancing CTA images, such as CTAtMIP and CTAtAve extracted from CTP. MATERIALS AND METHODS: The data of forty-seven patients who underwent CTP at 80 kVp were retrospectively collected. Four sets of images: CTApeak, CTAtMIP, CTAtAve, and CE-boost images. The CTApeak image represents the arterial phase at its peak value, captured as a single time point. CTAtMIP and CTAtAve are 4D CTA images that provide maximum density projection and average images from the three most prominent time points. CE-boost is a postprocessing technique used to enhance contrast in the arterial phase at its peak value. We compared the average CT value, standard deviation (SD), signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) of the internal carotid artery (ICA) and basilar artery (BA) among the four groups. Image quality was evaluated using a 5-point scale. RESULTS: The CE-boost demonstrated and CNR in the ICA and BA (all p < 0.001). Compared with the other three CTA reconstructed images, the CE-boost images had the best subjective image quality, with the highest scores of 4.77 ± 0.43 and 4.87 ± 0.34 for each reader (all p < 0.001). CONCLUSION: Compared with other currently used techniques,CE-boost enhances the image quality of CTA derived from 80-kVp CTP data, leading to improved visualization of intracranial arteries.

Measuring global cerebrovascular pulsatility transmission using 4D flow MRI.

Pulse wave encephalopathy (PWE) is hypothesised to initiate many forms of dementia, motivating its identification and risk assessment. As candidate pulsatility based biomarkers for PWE, pulsatility index and pulsatility damping have been studied and, currently, do not adequately stratify risk due to variability in pulsatility and spatial bias. Here, we propose a locus-independent pulsatility transmission coefficient computed by spatially tracking pulsatility along vessels to characterise the brain pulse dynamics at a whole-organ level. Our preliminary analyses in a cohort of 20 subjects indicate that this measurement agrees with clinical observations relating blood pulsatility with age, heart rate, and sex, making it a suitable candidate to study the risk of PWE. We identified transmission differences between vascular regions perfused by the basilar and internal carotid arteries attributed to the identified dependence on cerebral blood flow, and some participants presented differences between the internal carotid perfused regions that were not related to flow or pulsatility burden, suggesting underlying mechanical differences. Large populational studies would benefit from retrospective pulsatility transmission analyses, providing a new comprehensive arterial description of the hemodynamic state in the brain. We provide a publicly available implementation of our tools to derive this coefficient, built into pre-existing open-source software.

Thrombectomy improves functional independence in severe basilar artery occlusion with favorable collateral circulation.

BACKGROUND AND PURPOSE: This study aimed to investigate the effect of collateral circulation on the outcomes of thrombectomy versus medical management alone in basilar artery occlusion (BAO) patients with varying stroke severities. METHODS: Data from the ATTENTION cohort were used to perform a post-hoc analysis comparing the outcomes of thrombectomy with medical management in BAO patients with varying degrees of collateral circulation and stroke severity. Basilar Artery on Computed Tomography Angiography (BATMAN) scores were used to quantify the collateral circulation, and the effect was estimated through a primary outcome of 90-day functional independence (modified Rankin Scale score, mRS ≤2). Favorable versus unfavorable BATMAN scores were analyzed as both continuous and categorical variables, and an adjusted multivariate regression model was applied. RESULTS: Among 221 BAO patients, thrombectomy significantly improved functional independence compared to medical management in patients with favorable BATMAN scores (aOR 7.75, 95% CI 2.78-26.1), but not in those with unfavorable BATMAN scores (aOR 1.33, 95% CI 0.28-6.92; pinteraction = 0.028). When treated as a continuous variable, increased BATMAN score was found to be associated with a higher likelihood of functional independence in the thrombectomy group (aOR 1.97, 95% CI 1.44-2.81; pinteraction = 0.053). In severe stroke patients with higher BATMAN scores (National Institutes of Health Stroke Scale (NIHSS) ≥21), we identified a significant interaction for treatment effect with thrombectomy compared to medical management (pinteraction = 0.042). CONCLUSION: An increased BATMAN score was significantly associated with a higher probability of functional independence after thrombectomy than after medical management, particularly in patients with severe BAO.

Treatment of acute basilar artery occlusion by retrograde puncture via the vertebral artery approach: A care-compliant case report.

BACKGROUND: Vertebral artery stump syndrome (VASS) is a cause of acute stroke. Owing to the particularity of the pathogenesis of VASS, interventional treatment of VASS is difficult. Common mechanical thrombectomy approaches include femoral and radial artery approaches. However, conventional approaches may not be suitable for VASS. If effective measures are not taken to open offending vessels in time, this can lead to a high rate of disability. In recent years, no consensus has been reached regarding surgical methods for treating VASS. PATIENT CONCERNS: The patient presented to the emergency department with a 2-hour history of disturbance of consciousness. DIAGNOSIS: After neurological and magnetic resonance imaging examinations, the patient was diagnosed with acute large vessel occlusive posterior circulation cerebral infarction. METHODS: The patient's symptoms were not relieved after intravenous infusion of argatroban (10 mg) at a local hospital. We first attempted to open the occluded vertebral artery through normal approaches but failed. We then punctured the vertebral artery, successfully opened the occluded vertebral artery, and performed mechanical thrombectomy. RESULTS: The patient underwent successful vertebral artery puncture and mechanical thrombectomy, with no evidence of postoperative bleeding or vascular injury at the puncture site. The patient regained consciousness the day after surgery but remained impaired in physical activity. After 4 months of rehabilitation, the patient recovered completely. CONCLUSION: When the conventional approach cannot meet the requirements of mechanical thrombectomy, reverse puncture of the vertebral artery is a feasible surgical method for patients with VASS. However, due to the small number of cases, a series of safety problems such as potential puncture failure, hemorrhage after puncture, and vascular occlusion still need to be further explored.

Basilar artery stenting in hyperacute stroke: A systematic review of published cases.

BACKGROUND AND PURPOSE: Basilar artery stenting is a rescue therapy in the management of hyperacute stroke. Published data on efficacy and safety are limited. METHODS: A systematic review of published studies was performed in accordance with PRISMA guidelines. Inclusion criteria were adult patients with ischemic stroke with permanent basilar artery stent placement within 48 h of onset. Data were extracted by two independent reviewers. Additional cases from our institution were identified via a local stroke registry. RESULTS: Of 212 screened articles, patient-level data was reported in 35 studies (87 individuals) and six additional patients were included from our registry. Patients (n = 93, 63 % male; median age 64) most often presented with mid-basilar occlusion (52 %) and 76 % received treatment within 12 hours of onset. Favorable angiographic results occurred in 67 %. The final modified Rankin Scale score (mRS) was 0-3 for 56 % of patients; mortality was 29 %. Those with complete flow post-procedure were more likely to have a final mRS of 0-3 (p = 0.05). CONCLUSIONS: In 93 cases of basilar stenting in hyperacute stroke, favourable angiographic and functional outcomes were reported in 67 % and 56 % of patients, respectively. International multicenter registries are required to establish benefit and identify patient and technical factors that predict favorable outcomes.

[Basilar Artery, Anterior Inferior Cerebellar Artery, Superior Cerebellar Artery].

The basilar artery(BA)is formed by the fusion of two longitudinal arteries, and incomplete development may lead to BA fenestration. The BA provides many short perforating arteries and long lateral pontine arteries to the brain stem. The anterior inferior cerebellar artery(AICA)usually branches from the proximal third of the BA and primarily perfuses the ventral, inferior and lateral aspect of the cerebellum and inner ear organ. However, there are many variations to the AICA that depend on the degree of posterior inferior cerebellar artery development. The superior cerebellar artery(SCA)branches into not only to the rostral, ventral aspect of the cerebellar hemisphere, but also to the deeper cerebellar nucleus and brain stem. Duplications within this vessel are frequently identified, but it is not missing.

Chronic basilar artery occlusion: a retrospective monocentric study.

BACKGROUND: Acute basilar artery occlusion is a life-threatening medical emergency with a highly elevated mortality rate when left untreated. Little is known about symptoms and clinical progression of chronic occlusions. The aim of this study was to systematically analyze the clinical presentation of patients with chronic basilar artery occlusion (CBAO). METHODS: Monocentric retrospective analysis of adult patients with CBAO was treated between 2015 and 2023 in the Department of Neurology, Klinikum Kassel. Inclusion criteria were basilar artery occlusion without brainstem infarction as well as patients with a basilar artery occlusion in whom revascularization could not be achieved and a follow-up period of at least 3 months. RESULTS: A total of 15 patients were found. In five patients basilar artery occlusion was diagnosed as an incidental finding, four patients had neurological symptoms but no proven brainstem infarction (3 × transient ischemic attack, 1 × isolated posterior artery infarct) and six patients presented with acute basilar artery occlusion and a follow-up > 3 months. The most common site of occlusion was midbasilar (80%, n = 12), isolated (n = 7) or in combination with other locations (n = 5). In all cases collateralization could be demonstrated by the posterior communicating arteries. The most common vascular risk factors (VRF) were hypertension (100%) and hypercholesterolemia (67%). CONCLUSIONS: Patients with CBAO may present with only mild symptoms or may even be asymptomatic. This condition may be survived for a long time. The high percentage of vascular risk factors and further cerebral vessel occlusions suggest arteriosclerosis as the major causing factor of CBAO.

Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients.

BACKGROUND: Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with anterior circulation emergent large vessel occlusion (ELVO) strokes. With recent publication of two randomized controlled trials in favor of EVT for basilar artery occlusions, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee provides this focused update for the existing SNIS guideline, 'Current endovascular strategies for posterior circulation large vessel occlusion stroke.' METHODS: A structured literature review and analysis of studies related to posterior circulation large vessel occlusion (basilar or vertebral artery) strokes treated by EVT was performed. Based on the strength and quality of the evidence, recommendations were made by consensus of the writing committee, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: Based on the results of the most recent randomized, controlled trials on EVT for basilar or vertebral artery occlusion, the expert panel agreed on the following recommendations. For patients presenting with an acute ischemic stroke due to an acute basilar or vertebral artery occlusion confirmed on CT angiography, National Institutes of Health Stroke Scale (NIHSS) score of ≥6, posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) ≥6, and age 18-89 years: (1) thrombectomy is indicated within 12 hours since last known well (class I, level B-R); (2) thrombectomy is reasonable within 12-24 hours from the last known well (class IIa, level B-R); (3) thrombectomy may be considered on a case by case basis for patients presenting beyond 24 hours since last known well (class IIb, level C-EO). In addition, thrombectomy may be considered on a case by case basis for patients aged <18 years or >89 years on a case by case basis (class IIb, level C-EO). CONCLUSIONS: The indications for EVT of ELVO strokes continue to expand and now include patients with basilar artery occlusion. Further prospective, randomized controlled trials are warranted to elucidate the efficacy and safety of EVT in populations not included in this set of recommendations, and to confirm long term outcomes.

Second trimester screening for the basilar artery: a new approach using slowflowHD.

OBJECTIVES: Sonographic evaluation of the basilar artery is challenging, and a limited number of reports are available about the prenatal period, as manual positioning of probes is technically difficult. The objective of this study was to describe a sonographic transabdominal approach based on slowflow HD for screening of the basilar artery during the second trimester scan. METHODS: A total of 49 women who were enrolled in a second trimester screening were included when the fetus was in the occipitoanterior position. Dopper screening of the cerebral artery was performed, which revealed the "Y" sign indicating the basilar trunk arising from two vertebral arteries in the axial oblique view when the probe was located around the junction of the vertebral processes and occipital bone and was superior to the first vertebral body, sloping slightly to the cephalic side. The Doppler ultrasound probe was placed perpendicular to the basilar artery. The flow direction was below the baseline, away from the probe in the basilar artery, consistent with a caudocephalic orientation. Peak systolic and diastolic velocities were measured. RESULTS: The basilar artery was identified in all 49 fetuses, with a mean gestational age of 22 weeks (range 20 to 26 weeks). The mean peak systolic velocity of the basilar artery was 15.8 cm/second (range 9.12-26.44 cm/second). There was a slight increase in peak systolic velocity according to the gestational age of the fetus. CONCLUSIONS: This study demonstrated that evaluation of the basilar artery can be performed during the second trimester via a new transabdominal approach involving slowflow HD.

Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms.

BACKGROUND: Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms. METHODS: Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls. RESULTS: 9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2. CONCLUSIONS: Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.

Computed tomography perfusion deficit volume predicts the functional outcome of endovascular therapy for basilar artery occlusion.

OBJECTIVES: To investigate the relationship between baseline computed tomography perfusion deficit volumes and functional outcomes in patients with basilar artery occlusion (BAO) undergoing endovascular therapy. METHODS: This was a single-center study in which the data of 64 patients with BAO who underwent endovascular therapy were retrospectively analyzed. All the patients underwent multi-model computed tomography on admission. The posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score was applied to assess the ischemic changes. Perfusion deficit volumes were obtained using Syngo.via software. The primary outcome of the analysis was a good functional outcome (90-day modified Rankin Scale score ≤ 3). Logistic regression and receiver operating characteristic curves were used to explore predictors of functional outcome. RESULTS: A total of 64 patients (median age, 68 years; 72 % male) were recruited, of whom 26 (41 %) patients achieved good functional outcomes, while 38 (59 %) had poor functional outcomes. Tmax > 10 s, Tmax > 6 s, and rCBF < 30 % volume were independent predictors of good functional outcomes (odds ratio range, 1.0-1.2; 95 % confidence interval [CI], 1.0-1.4]) and performed well in the receiver operating characteristic curve analyses, exhibiting positive prognostic value; the areas under the curve values were 0.85 (95 % CI, 0.75-0.94), 0.81 (95 % CI, 0.70-0.90), and 0.78 (95 % CI, 0.67-0.89). CONCLUSION: Computed tomography perfusion deficit volume represents a valuable tool in predicting high risk of disability and mortality in patients with BAO after endovascular treatment.

Microvascular Decompression for Trigeminal Neuralgia with Complicated Offending Vessel Involving Trigeminocerebellar Artery: 2-Dimensional Operative Video.

Microvascular decompression (MVD) is a well-established and definitive treatment option for trigeminal neuralgia (TN).1 However, complex vascular geometry and numerous offending vessels make it difficult to perform nerve decompression in certain cases.2 The trigeminocerebellar artery (TCA) is a unique branch of the basilar artery. The vessel is named the TCA because it supplies both the trigeminal nerve root and the cerebellar hemisphere.3 This anatomical variant may increase the risk of neurovascular compression in the trigeminal nerve. We present the case of a 74-year-old man with left TN in whom a TCA was one of the responsible compression vessels. Preoperative images revealed the ipsilateral anterior inferior cerebellar artery, well-developed TCA, and superior cerebellar artery, wherein these branches were all suspected to be involved in trigeminal nerve compression. In MVD, 3 arteries were suspected to compress the trigeminal nerve in 5 sites, and all of them needed to be meticulously dissected from the nerve root and decompressed. Moreover, 2 of them branched many short perforators to the brainstem. Three decompression procedures (transposition to the dura, transposition to the brain, and interposition) were performed to decompress the trigeminal nerve. Postoperatively, TN was completely resolved immediately. MVD for TN could be difficult to perform in cases with TCA, as in the present case, and rigorous procedures were required intraoperatively.