[Treatment of atherosclerotic lesion of the first segment of subclavian artery]. / Lechenie ateroskleroticheskogo porazheniya pervogo segmenta podklyuchichnoi arterii.

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Sudden bilateral deafness in a patient with vertebrobasilar artery occlusion: A case report.

RATIONALE: Sudden bilateral deafness is often associated with serious systematic conditions such as neoplasms, vascular events, autoimmune diseases, infections, and iatrogenic injury, but very rarely to cerebrovascular disease. This is a rare case of sudden bilateral deafness in a patient with the vertebrobasilar artery occlusion. PATIENT CONCERNS: A 46-year-old man was admitted to a local hospital for sudden bilateral deafness, the patient suffered inarticulate speech and walking unsteadily 6 days later. DIAGNOSES: Difusion-weighted magnetic resonance imagin demonstrated acute cerebral infarction in the pons and bilateral cerebellum; Magnetic resonance angiography showed vertebrobasilar artery occlusion. INTERVENTIONS: Aspirin and clopidogrel were given for antiplatelet therapy, revascularization was obtained by endovascular treatment. OUTCOMES: The symptoms of dysarthria, ataxia and weakness gradually improved and were discharged 14 days after admission revascularization. After 3 months telephone followed-up the patient was self-cared. LESSONS: Deafness sometimes can be an early warning sign of impending vertebrobasilar ischemic stroke. Early recognition of deafness with acute ischemic stroke should allow special management, and misdiagnosis may result in significant morbidity, or even mortality.

Supplementingand activating blood circulation method to treat vertebrobasilar dolichoectasia with posterior circulatory watershed infarction: a case report of two patients.

Vertebrobasilar dolichoectasia (VBD), a rare posterior circulation vascular variant disease, is an important risk factor for many acute cerebrovascular diseases. An insufficient understanding of VBD often leads to misdiagnose. Two cases of VBD that were initially diagnosed as posterior circulation watershed infarction are reported here. Absence of common causes of stroke including hypoperfusion, blood system diseases, carotid and aortic dissection, and eosinophil elevation, the symptoms of the 2 patients met the diagnostic criteria of VBD. Both patients displayed symptoms that were in line with the Traditional Chinese Medicine (TCM) syndrome pattern of "deficiency and blood stasis". Accordingly, they were comprehensively treated with Supplementingand activating blood circulation method. The clinical manifestations of the 2 patients were remarkably improved and no recurrence of watershed infarction was found in a 1-year follow-up. A detailed medical history and laboratory examination are capable of improving diagnostic accuracy of VBD. TCM treatment based on syndrome identification might be a promising candidate for VBD management.

Thyroid Cartilage Compression Causing Bow Hunter's Syndrome.

OBJECTIVES AND METHODS: We report a unique case of Bow Hunter's syndrome with a dominant aberrantly coursing right vertebral artery (VA), presenting with persistent dizziness and syncope despite previous decompressive surgery at vertebral levels C5-C6. RESULTS: Re-evaluation with computed tomography-scan during provocation of dizziness by neck rotation revealed compression of the right VA at level C6 from against the ipsilateral posterior border and superior cornu of the thyroid cartilage. Laryngoplasty resulted in complete resolution of symptoms. CONCLUSION: This extremely rare cause of Bow's Hunter's syndrome should be considered, especially in refractory cases after neurosurgical decompression, and surgical management is straightforward and successful.

Vertebral Artery Interventions: A Comprehensive Updated Review.

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis are promising options widely used in clinical practice with good technical results; however, the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. This review aims to provide a focused update on the percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach, and advances in medical therapies.

What you need to know about: arterial cerebrovascular syndromes caused by static or dynamic musculoskeletal compression.

Compressive syndromes of the cervical arteries caused by musculoskeletal structures include bow hunter's syndrome, beauty parlour stroke syndrome, carotid compression by the hyoid bone, carotid compression by the digastric muscle and Eagle syndrome. They are a rare but increasingly recognised group of syndromes, so a high level of suspicion is needed so the diagnosis is not missed. The diagnosis is typically based on a combination of clinical history and advanced imaging investigations. Compression of the arteries may be static (only provoked by compression) or dynamic (exaggerated by movement), and this should be considered when selecting imaging studies. Symptoms resulting from vertebrobasilar insufficiency or ischaemia of areas supplied by the internal carotid artery are caused by compression of the vertebral artery and the internal carotid artery respectively. Surgical procedures are the preferred treatment for most of these syndromes.

Basilar Artery Fenestration Versus Hypoglycemia-Induced Vertebrobasilar Insufficiency: A Case Report.

PURPOSE: Vertebrobasilar insufficiency (VBI) is a common transient neurological condition related to posterior circulation hemodynamic insufficiency. However, it is rarely seen as an initial presentation in basilar artery (BA) fenestration or hypoglycemia. We present this case to further clarify the association between BA fenestration and hypoglycemia-induced VBI, as well as the difficulty in diagnosis, especially in acute clinical settings. CASE REPORT: Herein, we report a case with BA fenestration, in which the patient suffered from transient episodes of focal neurological deficits, including dysarthria, focal limbs weakness, and ataxia with subsequent total recovery. Apart from hypoglycemia, no other abnormal laboratory surveys were found. This concurrent finding of hypoglycemia with transient focal neurological deficit poses a difficulty in differentiating between hypoglycemia-induced VBI and true acute ischemic stroke in the clinical setting. Subsequent brain imaging studies revealed no evidence of acute infarction and no evidence of atherosclerosis changes in vessels but BA fenestration was observed. We prescribed antiplatelets for the prevention of future strokes. However, currently, no consensus exists regarding the prevention of cerebral ischemia with BA fenestration. CONCLUSION: BA fenestration-induced VBI and hypoglycemia-induced VBI are rarely reported and their mechanisms of action remain uncertain and controversial. However, BA fenestration-induced VBI may pose a risk for future cerebral ischemic events and warrants further investigations.

Posterior Circulation Ischaemic Stroke.

Posterior circulation ischaemic stroke (PCIS) is a disease of high mortality and morbidity. They account for 20-25% of all ischaemic strokes. However, it is relatively under-researched and requires more clinical attention, since it carries worse functional outcomes. Vertigo, visual disturbances and sensory/motor disturbances are commonly observed in patients with PCIS. Large artery atherosclerosis and embolism are the main causes of PCIS, while there is growing evidence that vertebrobasilar dolichoectasia is a key associative factor. Hypertension is the most common risk factor, while diabetes mellitus is more specific to PCIS. PCIS is diagnosed through a range of neuroimaging techniques, which respectively examine structural brain abnormalities, vascular patency and perfusion. PCIS, in line with ischaemic stroke in general, necessitates medical treatment and lifestyle modifications. This includes smoking cessation, weight control, and alterations in dietary habits. Aspirin use also significantly improves survival outcomes. While intravascular and intra-arterial thrombolysis improve clinical outcomes, this is not proven conclusively for stenting and angioplasty. Future research on PCIS can focus on multi-centre epidemiological studies, clinically significant anatomical variants, and collateralisation.

Rotational Vertebrobasilar Insufficiency: Is There a Physiological Spectrum? Phase-Contrast Magnetic Resonance Imaging Quantification in Healthy Volunteers.

BACKGROUND: Some cases of cerebral ischemia have been attributed to dynamic flow limitation in neck vessels. It however remains unknown whether this represents the extreme end of a physiological response. METHODS: Eighteen healthy volunteers were recruited to this prospective study. Cervical blood flow (ml/min/m2) was assessed using phase-contrast MRI, and cerebral perfusion ratios were assessed using arterial spin labeling perfusion at neutral position, predefined head rotations, as well as flexion and extension. Inter-reader agreements were assessed using intraclass correlation coefficient. RESULTS: The mean age was 38.6 ± 10.8 (range = 22-56) years, for five male participants and 13 females. The means for height and weight were 168 cm and 73.2 kg, respectively. There were no significant differences in individual arterial blood flow with change in head position (P > 0.05). Similarly, the repeated-measures analysis of variance test demonstrated no significant difference in perfusion ratios in relation to head position movement (P > 0.05). Inter-reader agreement was excellent (intraclass correlation coefficient = 0.97). CONCLUSIONS: There is neither significant change in either individual cervical arterial blood flow nor cerebral perfusion within the normal physiological/anatomical range of motion in healthy individuals. It is therefore reasonable to conclude that any such hemodynamic change identified in a patient with ischemic stroke be considered causative.

Dynamic observation on collateral circulation construction of patient with vertebral artery restenosis after stenting: case report.

Purpose/aim of the study: Posterior circulation stroke (PCS) accounts for 20% of ischemic stroke, and vertebrobasilar stenosis is an important cause of PCS. Notably, not all patients with artery stenosis progress to ischemic stroke, and one of the important reason is that collateral circulation construction plays important protection role in this process.Clinical presentation: Here, we present the case of a 71-year-old male who presented with lightheadedness and three episodes of loss of consciousness after bilateral subclavian artery stenting. Digital subtraction angiography (DSA) demonstrated severe stenosis of the left vertebral artery, and the bilateral subclavian artery was kept open. The patient was then given the left vertebral artery stenting in an effort to resolve the vascular stenosis. As expected, he achieved a complete remission after stenting. However, 6 months later the patient suffered from loss of consciousness again. Repeat DSA confirmed restenosis of the left vertebral artery, and revealed a collateral flow to the left vertebral artery which fed by external carotid collateral branches. Then DSA was performed after 12 months, and another collateral circulation involving thyrocervical trunk was also found supplying flow to the left vertebral artery. In this process, the frequency of loss of consciousness gradually decreased as the collateral circulation construction. Conclusion: Through this case, we observe the whole process of the collateral circulation construction. Moreover, this case serves as a testament to the variability and complexity of vertebrobasilar arteriopathies, suggesting promotion of collateral flow offers the opportunity for outcome improvement.

Free-floating and spinning thrombus of the basilar artery: A case report.

RATIONALE: Free-floating thrombi in the intracranial artery are rare. We report a case of a free-floating and spinning thrombus caused by turbulent flow distal to the basilar artery stenosis. We compare thrombus changes in a series of images according to time and describe the approach to treatment and thrombosis resolution.. PATIENT CONCERNS: A 55-year-old man presented to the emergency department on March 21, 2020, with left-sided weakness, bilateral limb ataxia, and a one-day history of dysarthria. Brain magnetic resonance imaging showed multifocal infarctions in the pons and cerebellum with severe basilar stenosis. DIAGNOSES: Digital subtraction angiography showed severe focal stenosis. A relatively large oval-shaped mobile thrombus was observed spinning due to turbulent flow at the distal portion of the stenosis. INTERVENTIONS: We administered a combination antithrombotic regimen of warfarin and clopidogrel for 50 days. OUTCOMES: No thrombus was observed on the third follow-up digital subtraction angiography. LESSONS: No previous study has directly observed a mobile thrombus in the intracranial artery using digital subtraction angiography. We used a combination antithrombotic strategy, which was effective after long-term, rather than short-term, use.

New diagnostic algorithm for detection of covert Bow Hunter's Syndrome.

Bow hunter's syndrome (BHS) should not be overlooked as a cause of cerebral infarction in the posterior circulation. However, covert BHS, which does not impair blood flow with simple rotation but only at certain angles, may make the diagnosis of BHS difficult. We propose a new algorithm to detect BHS or covert BHS. We recommend that BHS and covert BHS be detected by noninvasive duplex ultrasonography, which will allow for appropriate treatment.

Validation of a Polish version of the Israeli Vertebrobasilar Stroke Scale - An attempt to more accurately assess posterior Stroke.

OBJECTIVE: Posterior circulation stroke, in contrast to anterior circulation stroke, has a greater complexity and variability of clinical symptoms. This could be responsible for delayed diagnosis and treatment time and, as a consequence, worse prognosis. Certain blame in this respect can also be attributed to the clinimetric scales used to assess stroke severity, which are characterized by significantly lower accuracy than with anterior strokes. The Israeli Vertebrobasilar Stroke Scale (IVBSS) was the first attempt dedicated to posterior strokes and was devised for better measurement of clinical condition. We aimed to develop a Polish version of the IVBSS (PL-IVBSS) to assess the reliability, validity and psychometric properties of the tool to confirm its clinical utility. METHODS: We enrolled 126 posterior circulation ischemic stroke subjects. Four researchers estimated stroke severity using appropriate and widely accepted devices (the modified Rankin Scale - mRS, the National Institutes of Health Stroke Scale - NIHSS, the Barthel Index, and the Glasgow Coma Scale - GCS) and compared with the PL-IVBSS. We analyzed inter- and intrarater agreements, repeatability, concurrent and predictive validity, internal consistency, scalability and homogeneity, reflecting the psychometric features of a validated instrument. RESULTS: Cronbach's alpha coefficient was 0.67, and the median inter-item correlation coefficient was 0.22, indicating moderate internal consistency and insufficient homogeneity. A total of 63.6% of the individual items obtained required discriminatory power (r > 0.3), showing moderate scalability. The PL-IVBSS achieved a good coefficient of repeatability (CR = 1.21 95%CI 1.08-1.38) and narrow limits of agreement in Bland-Altman analysis, emphasizing the accuracy and high reproducibility. Excellent intraclass correlation coefficients and weighted kappa values (all >0.90) underlined the high reliability of the PL-IVBSS. Highly significant correlations with other relevant devices (all r > 0.5, p < 0.0001) highlighted the satisfactory concurrent and predictive validity of a validated clinimetric tool. CONCLUSION: We devised a validated version of the IVBSS, indicating the high reproducibility, repeatability and accuracy of the PL-IVBSS and confirming its clinical utility. Despite moderate psychometric properties, our findings support the need for its clinical application and widespread use in stroke units for a reliable assessment of posterior stroke severity.

Relationship Between Acute Neurological Function and Long-Term Prognosis in Patients with Large Arterial Occlusions.

OBJECTIVES: To clarify the relationship between early neurological symptoms and long-term functional outcomes of acute ischemic stroke, which would be beneficial for patient management and determining clinical study criteria of novel therapeutic interventions. MATERIALS AND METHODS: We retrieved data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) and investigated the association between 24- and 72-hour National Institutes of Health Stroke Scale (NIHSS) and 90-day modified Rankin Scale (mRS) scores, stratified by the site of occlusion (carotid or vertebrobasilar circulatory large arterial occlusion [ACO or PCO, respectively]) and endovascular recanalization therapy (EVT) performance. We examined the correlation using Spearman's rank correlation coefficient (rho). Predictive accuracies of 24- and 72-hour NIHSS scores for good outcomes at 90 days (defined as mRS score of 0-2) were evaluated by receiver operating characteristic (ROC) analyses and the corresponding areas under the curves (AUCs). RESULTS: Among the 2420 patients, 1745 had ACO (971 with EVT, 774 without EVT) and 263 had PCO (127 with EVT, 136 without EVT). The 24- and 72-hour NIHSS scores were significantly associated with 90-day mRS scores and accurately predicted good outcomes (all rhos ≥0.76, all AUCs ≥0.86). In the ACO group, there were differences in rho and AUC depending on EVT performance and the time from onset to NIHSS acquisition, but no differences were observed in the PCO group. CONCLUSIONS: EVT performance and time frame should be considered when determining the criteria of novel therapeutic interventions, especially for patients with ACO.

Transitional nystagmus in a Bow Hunter's Syndrome case report.

BACKGROUND: Bow Hunter's Syndrome (BHS) is known as one of cervical diseases which causes vertigo, but the details of its vertigo, especially nystagmus and eye movement, are still incompletely understood. This time, we reported the first case of BHS with a nystagmus chart with video record of transitional nystagmus. CASE PRESENTATION: The patient, a 47-year-old female, complained of vertigo caused by head rotation. When she turned her head leftward, leftward nystagmus appeared, and this was followed by dullness of the right arm. After her head was returned to the central position, downbeat nystagmus appeared, which changed to rightward nystagmus. She was diagnosed with BHS by her symptoms and images. We recorded a nystagmus video and nystagmus chart of this transitional nystagmus including downbeat nystagmus. Her vertigo was cured by the modification of a prescription for her past medical history: hypertension. CONCLUSION: The vertigo of BHS accompanies nystagmus. In this present case, the transitional nystagmus was observed, and it occurred toward the healthy side. Then the nystagmus direction was changed to the affected side via downbeat nystagmus. This is the first report with both a nystagmus chart with video of BHS. Nowadays, various kinds of vertigo induced by neck movement are known. BHS is a rare disease among vertigo diseases, but we should consider it as a different diagnosis of vertigo patients. A precise interview and proper examination are required to make the final diagnosis.

Bow hunter's syndrome after cervical laminoplasty in a patient with rheumatoid arthritis with bony ankylosis in the cervical spine: a case report.

Bow hunter's syndrome, or rotational vertebral artery (VA) occlusion, refers to vertebrobasilar insufficiency due to mechanical occlusion of the VA. We present a case of surgical treatment for bow hunter's syndrome that occurred after cervical laminoplasty in a patient with rheumatoid arthritis with bony ankylosis of the facet joints. A 59-year-old female with rheumatoid arthritis experienced sudden incomplete left hemiplegia. Fifteen months earlier, the patient had undergone cervical decompression surgery between C3 and C7. MRI of the head showed cerebral infarction in the right VA area, while vertebral angiography with the head rotated to the right revealed that the right VA was occluded at the level of C3-C4. The patient was successfully treated via posterior cervical fusion from C2 to C7. Patients with rheumatoid arthritis have a potential risk of cervical bony ankyloses. Cervical laminoplasty for patients with cervical bony ankyloses can induce rotational VA occlusion due to spinal rotational instability.