Basilar artery curvature increases the risk of posterior circulation infarction occurrence in patients without vertebrobasilar stenosis.

INTRODUCTION: Limited cross-sectional or case-control studies have identified the relationship between basilar artery (BA) curvature and posterior circulation infarction (PCI). This study aimed to identify the influence of BA curvature severity on the risk of PCI occurrence in patients without vertebrobasilar stenosis through a prospective cohort study. METHODS: In this study, we enrolled 171 patients with BA dolichosis but without vertebrobasilar stenosis. The BA geometric parameters were evaluated on MRA. The primary outcome was the occurrence of PCI, mainly referring to cerebellar and/or brainstem infarction. Cox proportional hazard models were used to detect possible predictors of PCI. RESULTS: Among them, 134 (78.4%) patients were diagnosed with BA curvature, including 124 with moderate curvature and 10 with prominent curvature. The defined PCI occurrence was observed in 32 (18.7%) patients with a median follow-up time of 45.6 months. Cox proportional hazard analysis showed that BA prominent curvature (HR = 6.09; 95% CI: 1.36-27.28; P = 0.018) significantly increased the risk of PCI occurrence, and bending length (BL) was also significantly associated with PCI occurrence, with the adjusted HR per 1-mm increase of BL of 1.09 (95% CI: 1.01-1.18; P = 0.040). In the subgroup analysis stratified by age, BA prominent curvature was highly associated with PCI occurrence in patients aged > 61 years (HR = 11.76; 95% CI: 1.21-113.90; P = 0.033). Additionally, good antiplatelet therapy adherence could significantly reduce the risk of PCI occurrence. CONCLUSION: BA curvature may increase the risk of PCI occurrence, especially in elderly patients with prominent curvature. Improving adherence to antiplatelet therapy can help reduce the risk of PCI occurrence.

Prevalence and Clinical Correlates of Intracranial Dolichoectasia in Individuals With Ischemic Stroke.

Background and Purpose: Acute ischemic stroke is a known complication of intracranial dolichoectasia (IDE). However, the frequency of IDE causing brain infarction is unknown. We aim to determine the prevalence and clinical correlates of IDE in acute ischemic stroke by employing an objective IDE definition for major intracranial arteries of the anterior and posterior circulation. Methods: Consecutive patients with acute ischemic stroke admitted to a tertiary-care hospital during a 4-month period were analyzed. Intracranial arterial diameter, length, and tortuosity were determined by semiautomatic vessel segmentation and considered abnormal if ≥2 SDs from the study population mean. Either ectasia (increased diameter) or dolichosis (increased length or tortuosity) of at least one proximal intracranial artery defined IDE. Symptomatic IDE was considered when the infarct was located in the territory supplied by an affected artery in the absence of any alternative pathogenic explanation. Multivariate models were fitted to determine IDE clinical correlates. Results: Among 211 cases screened, 200 patients (mean age 67±14 years, 47.5% men) with available intracranial vessel imaging were included. IDE was identified in 24% cases (5% with isolated ectasia, 9.5% with isolated dolichosis, and 9.5% with both ectasia and dolichosis). IDE was considered the most likely pathogenic mechanism in 12 cases (6% of the entire cohort), which represented 23.5% of strokes initially categorized as undetermined cause. In addition, 21% of small-artery occlusion strokes had the infarct territory supplied by a dolichoectatic vessel (3% of the entire cohort). IDE was independently associated with male sex (odds ratio, 4.2 [95% CI, 1.7­10.6]) and its component of ectasia was associated with advanced age (odds ratio, 3.5 [95% CI, 1.3­9.5]). Vascular risk profile was similar across patients with stroke with and without IDE. Conclusions: Our findings suggest that IDE is an arteriopathy frequently found in patients with acute ischemic stroke and is likely responsible for a sizable fraction of strokes initially categorized as of undetermined cause and perhaps also in those with small-artery occlusion.

Incidence, risk, and treatment of binary restenosis after vertebral artery stenting.

BACKGROUND: In-stent restenosis (ISR) is the major concern of vertebral artery stenting (VAS). We aimed to investigate the feasibility and outcome of redo angioplasty for ISR of vertebral artery. METHOD: The patients were retrospectively reviewed for the significant ISR (>50%). Redo angioplasty including balloon angioplasty and stenting was performed for symptomatic ISR (>50%) or asymptomatic ISR (≥70%). The clinical follow-up was performed on the 1, 3, 6, and 12 months and then yearly in the clinic or by telephone. The angiographic follow-up was performed at 6-12 months after redo angioplasty. RESULT: A total of 72 patients had significant ISR and 48 redo angioplasty (92.3%, 48/52) were successfully achieved with 13 located in the V4 and 35 in the ostium of vertebral artery. Twenty-six lesions were implanted by the second stent and the others received balloon angioplasty. No stroke or transient ischemic attack (TIA) occurred in the perioperative time. One patient died 2 months after redo angioplasty due to nonstroke cause. Redo angioplasty nonsignificantly decreased the stroke or TIA compared with medical treatment. Sixteen patients developed the binary restenosis, which was lower in the patients receiving stent implantation than balloon angioplasty. CONCLUSION: Redo angioplasty was a feasible method for the ISR of VAS and redo stenting might be the first choice.

Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site.

BACKGROUND: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. METHODS: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. RESULTS: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). CONCLUSIONS: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.

Prevalence of asymptomatic atherosclerosis of extracranial vessels among hypertensive patients in southern Egypt: An extracranial duplex study.

OBJECTIVE: The prevalence of atherosclerosis in extracranial vessels among hypertensive patients in southern Egypt is still unknown. Carotid ultrasound is an accurate method used to identify and follow patients with cerebrovascular disorders. The aim of our study is to detect the prevalence and pattern of extracranial atherosclerosis among those patients. METHODS: Our case-control study was performed from January 2017 to January 2018, including 200 subjects, 100 patients recruited consecutively from the Hypertension Clinic in Assiut University hospitals, Egypt, and 100 healthy controls. Detailed history collection and thorough physical examinations were carried out for each patient. All subjects underwent extracranial ultrasound. We omitted patients with history of ischemic stroke and TIAs. RESULTS: The presence of increased intima media thickness was detected in 37 patients (37%). 22 patients (22%) had internal carotid artery (ICA) stenosis, 17 patients (17%) had non-significant stenosis <50%, while five patients (5%) had stenosis 50-69%. 9% had stenosis < 50% in vertebral artery. In addition, age and uncontrolled hypertension have a greater impact on increasing the CCA intima media thickness, which is considered an early sign of atherosclerosis. CONCLUSION: Uncontrolled hypertension is an important risk factor for atherosclerosis and hence ischemic stroke (IS). The cost of screening is considered low compared to IS management. Greater emphasis should be directed toward regular screening programs in this risky population.

One-Year Risk of Recurrent Stroke and Death Associated with Vertebrobasilar Artery Stenosis and Occlusion in a Cohort of 10,515 Patients.

BACKGROUND: The natural history of vertebrobasilar artery (VBA) stenosis or occlusion remains understudied. METHODS: Patients with diagnosis of ischemic stroke or transient ischemic attack (TIA) who were noted to have VBA stenosis based on computed tomography or magnetic resonance imaging or catheter-based angiogram were selected from Taiwan Stroke Registry. Cox proportional hazards model was used to determine the hazards ratio (HR) of recurrent stroke and death within 1 year of index event in various groups based on severity of VBA stenosis (none to mild: 0-49%; moderate to severe: 50-99%: occlusion: 100%) after adjusting for differences in demographic and clinical characteristics between groups at baseline evaluation. RESULTS: None to mild or moderate to severe VBA stenosis was diagnosed in 6972 (66%) and 3,137 (29.8%) among 10,515 patients, respectively, and occlusion was identified in 406 (3.8%) patients. Comparing with patients who showed none to mild stenosis of VBA, there was a significantly higher risk of recurrent stroke (HR 1.21, 95% CI 1.01-1.45) among patients with moderate to severe VBA stenosis. There was a nonsignificantly higher risk of recurrent stroke (HR 1.49, 95% CI 0.99-2.22) and significantly higher risk of death (HR 2.21, 95% CI 1.72-2.83), among patients with VBA occlusion after adjustment of potential confounders. CONCLUSIONS: VBA stenosis or occlusion was relatively prevalent among patients with TIA or ischemic stroke and associated with higher risk of recurrent stroke and death in patients with ischemic stroke or TIA who had large artery atherosclerosis.

Intracranial Arterial Dolichoectasia and Stenosis: Risk Factors and Relation to Cerebral Small Vessel Disease.

BACKGROUND AND PURPOSE: Intracranial arterial dolichoectasia (IADE) is a poorly understood arteriopathy compared with intracranial atherosclerotic stenosis (ICAS). We aimed to investigate the risk factors of IADE and ICAS and their relationship with neuroimaging markers of cerebral small vessel disease in a population-based study. METHODS: This study comprised 1237 participants (aged 57.2±9.4 years, 37.6% men) who underwent brain magnetic resonance imaging and magnetic resonance angiography. IADE was assessed based on basilar artery dolichoectasia (diameter, height of bifurcation, and laterality of basilar artery) and dilation of basilar artery and internal carotid artery (intracranial volume-adjusted diameter ≥2 SD). ICAS was defined as any degree of stenosis in at least 1 intracranial artery. The neuroimaging markers of cerebral small vessel disease, including lacunes, white matter hyperintensities, microbleeds, dilated perivascular spaces, and brain atrophy, were evaluated. RESULTS: Basilar arterial dolichoectasia was observed in 3.6% (45/1237); intracranial arterial dilation in 5.9% (67/1142); and ICAS in 15.7% (194/1237). Older age, higher systolic blood pressure, diabetes mellitus, higher LDL-C (low-density lipoprotein cholesterol) and lower HDL-C (high-density lipoprotein cholesterol) were associated with the presence of ICAS (all P<0.001), whereas only older age was associated with IADE. ICAS was associated with lacunes (odds ratio, 2.91; 95% confidence interval, 1.96-4.34; P<0.001), increased white matter hyperintensities volume (ß±SE, 0.54±0.13; P<0.001), and brain atrophy (ß±SE, -1.16±0.21; P<0.001), whereas basilar arterial dolichoectasia was mainly associated with dilated perivascular spaces in basal ganglia (odds ratio, 2.20; 95% confidence interval, 1.20-4.02; P=0.01) and, to a lesser extent, associated with lacunes and microbleeds. CONCLUSIONS: IADE and ICAS had different risk factor profiles and associated with different imaging phenotypes of cerebral small vessel disease, suggesting different underlying mechanisms.

Natural History of Vertebrobasilar Dolichoectatic and Fusiform Aneurysms: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Vertebrobasilar non-saccular and dolichoectatic aneurysms (VBDA) are a rare type of aneurysm and are generally associated with poor prognosis. In order to better characterize the natural history of VBDAs, we performed a systematic review and meta-analysis of the literature to determine rates of mortality, growth, rupture, ischemia, and intraparenchymal hemorrhage. MATERIALS AND METHODS: We searched the literature for longitudinal natural history studies of VBDA patients reporting clinical and imaging outcomes. Studied outcomes included annualized rates of growth, rupture, ischemic stroke, intracerebral hemorrhage (ICH), and mortality. We also studied the association between aneurysm morphology (dolichoectatic versus fusiform) and natural history. Meta-analysis was performed using a random-effects model using summary statistics from included studies. RESULTS: Fifteen studies with 827 patients and 5,093 patient-years were included. The overall annual mortality rate among patients with VBDAs was 13%/year (95% CI 8-19). Patients with fusiform aneurysms had a higher mortality rate than those with dolichoectatic aneurysms, but this did not reach statistical significance (12 vs. 8%, p = 0.11). The overall growth rate was 6%/year (95% CI 4-13). Patients with fusiform aneurysms had higher growth rates than those with dolichoectatic aneurysms (12 vs. 3%, p < 0.0001). The overall rupture rate was 3%/year (95% CI 1-5). Patients with fusiform aneurysms had higher rupture rates than those with dolichoectatic aneurysms (3 vs. 0%, p < 0.0001). The overall rate of ischemic stroke was 6%/year (95% CI 4-9). Patients with dolichoectatic aneurysms had higher ischemic stroke rates than those with fusiform aneurysms, but this did not reach statistical significance (8 vs. 4%, p = 0.13). The overall rate of ICH was 2%/year (95% CI 0-8) with no difference in rates between dolichoectatic and fusiform aneurysms (2 vs. 2%, p = 0.65). CONCLUSION: In general, the natural history of -VBDAs is poor. However, dolichoectatic and fusiform -VBDAs appear to have distinct natural histories with substantially higher growth and rupture associated with fusiform aneurysms. These findings suggest that these aneurysms should be considered separate entities. Further studies on the natural history of vertebrobasilar dolichoectatic and fusiform aneurysms with more complete follow-up are needed to better understand the risk factors for progression of these aneurysms.

Incidence and Predictors of the In-stent Restenosis after Vertebral Artery Ostium Stenting.

BACKGROUND: The incidence and predictors for in-stent restenosis (ISR) was not fully explored. We aim to investigate the incidence and predictors of ISR after stenting at the origin of vertebral artery. MATERIALS AND METHODS: Two hundred and six patients with 229 stents implantation between July 1, 2005 and July 31, 2015 were included in the study. All patients underwent conventional clinical and angiographic (digital subtraction angiography) follow-up at around 6 months post procedure. ISR was defined as greater than 50% stenosis within or immediately (within 5 mm) adjacent to the stent. Multivariate Cox regression analyses were utilized to investigate the predictors for ISR. RESULTS: The ISR was found in 30 patients (30/206, 14.6%) with 31 lesions (31/229, 13.5%) with the mean follow-up duration of 11.1-month (range: 3 - 92 months). Stent diameter (hazard ratio 0.504, 95% confidence interval 0.294 - 0.864) was an independent predictor for ISR. CONCLUSION: ISR rate after Vertebral artery ostium stent placement is acceptable, which was conversely associated with the stent diameter.

Vertebral Artery Occlusive Disease: Data from the Angiographically Confirmed Vertebral Artery Disease Registry.

BACKGROUND: We performed this study to identify demographic, clinical, and angiographic characteristics of adult patients with angiographically confirmed vertebral artery occlusive disease (VAOD) and associated risk factors. METHODS: The demographic and clinical characteristics, and angiographic features were ascertained using predefined criteria. Controls were selected from the National Health and Nutrition Examination Surveys matched according to age, sex, and ethnicity. A stepwise logistic regression for odds ratio (OR) was performed to identify the effects of risk factors on occurrence of VAOD. RESULTS: Of 56 patients with VAOD (mean age ± standard deviation [SD]; 65.4 ± 11.7years, 44.6% women), 37.5% were classified as suffering from moderate stenosis (50%-69%), 16.1% from severe stenosis (70%-99%), and 46.4% from occlusion of at least 1 vertebral artery. There was a significantly higher severity of stenosis (percentage with SD; 88.1 ± 16.5 versus 75.4 ± 20.8, P = .02) and frequency of bilateral vertebral artery disease in patients with ischemic symptoms (40.9% versus 8.8%, P = .004). In the multivariate analysis, hypertension (OR 3.0; 95% confidence interval [CI], 1.4-6.5), diabetes mellitus (OR 2.5; 95% CI, 1.4-4.6), coronary artery disease (OR 3.2; 95% CI, 1.7-6.0), and active cigarette smoking (OR 3.1; 95% CI, 1.5-6.3) were significantly associated with vertebral artery disease. CONCLUSIONS: Severity of stenosis and bilateral involvement were associated with symptomatic VAOD. Hypertension, diabetes mellitus, coronary artery disease, and active cigarette smoking were associated with occurrence of VAOD.

Dolichoectasia and Small Vessel Disease in Young Patients With Transient Ischemic Attack and Stroke.

BACKGROUND AND PURPOSE: We evaluated whether basilar dolichoectasia is associated with markers of cerebral small vessel disease in younger transient ischemic attack and ischemic stroke patients. METHODS: We used data from the SIFAP1 study (Stroke in Young Fabry Patients), a large prospective, hospital-based, screening study for Fabry disease in young (<55 years) transient ischemic attack/stroke patients in whom detailed clinical data and brain MRI were obtained, and stroke subtyping with TOAST classification (Trial of ORG 10172 in Acute Stroke Treatment) was performed. RESULTS: Dolichoectasia was found in 508 of 3850 (13.2%) of patients. Dolichoectasia was associated with older age (odds ratio per decade, 1.26; 95% confidence interval, 1.09-1.44), male sex (odds ratio, 1.96; 95% confidence interval, 1.59-2.42), and hypertension (odds ratio, 1.39; 95% confidence interval, 1.13-1.70). Dolichoectasia was more common in patients with small infarctions (33.9% versus 29.8% for acute lesions, P=0.065; 29.1% versus 16.5% for old lesions, P<0.001), infarct location in the brain stem (12.4% versus 6.9%, P<0.001), and in white matter (27.8% versus 21.1%, P=0.001). Microbleeds (16.3% versus 4.7%, P=0.001), higher grades of white matter hyperintensities (P<0.001), and small vessel disease subtype (18.1% versus 12.4%, overall P for differences in TOAST (P=0.018) were more often present in patients with dolichoectasia. CONCLUSIONS: Dolichoectasia is associated with imaging markers of small vessel disease and brain stem localization of acute and old infarcts in younger patients with transient ischemic attack and ischemic stroke. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583.

Epidemiology of Intracranial and Extracranial Large Artery Stenosis in a Population-Based Study of Stroke in the Middle East.

BACKGROUND: Intracranial large-artery disease (LAD) is a predominant vascular lesion found in patients with stroke of Asian, African, and Hispanic origin, whereas extracranial LAD is more prevalent among Caucasians. These patterns are not well-established in the Middle East. We aimed to characterize the incidence, risk factors, and long-term outcome of LAD strokes in a Middle-Eastern population. METHODS: The Mashhad Stroke Incidence Study is a community-based study that prospectively ascertained all cases of stroke among the 450,229 inhabitants of Mashhad, Iran between 2006 and 2007. Ischemic strokes were classified according to the TOAST criteria. Duplex-ultrasonography (98.6%), MR-angiography (8.3%), CT-angiography (11%), and digital-subtraction angiography (9.7%) were performed to identify involvements. Vessels were considered stenotic when the lumen was occluded by >50%. RESULTS: We identified 72 cases (15.99 per 100,000) of incident LAD strokes (mean age 67.6 ± 11.7). Overall, 77% had extracranial LAD (58% male, mean age 69.8 ± 10.3; 50 [89%] carotid vs. 6 [11%] vertebral artery), and the remaining 23% (56% male, mean age 60.2 ± 13.4; 69% anterior-circulation stenosis) had intracranial LAD strokes. We were unable to detect differences in case-fatality between extracranial (1-year: 28.6%; 5-year: 59.8%) and intracranial diseases (1-year: 18.8%; 5-year: 36.8%; log-rank; p = 0.1). CONCLUSION: Extracranial carotid stenosis represents the majority of LAD strokes in this population. Thus, public health strategies may best be developed in such a way that they are targeted toward the risk factors that contribute to extracranial stenosis.

Basilar Artery Dolichoectasia: Prevalence and Correlates With Markers of Cerebral Small Vessel Disease in Community-Dwelling Older Adults.

BACKGROUND: Basilar artery (BA) dolichoectasia has been associated with cerebral small vessel disease (SVD). However, studies have focused on stroke patients, and results cannot be extrapolated to the population at large. In this study, we aimed to assess prevalence of BA dolichoectasia and its association with SVD in community-dwelling older adults living in rural Ecuador. METHODS: Atahualpa residents aged ≥60 years underwent brain magnetic resonance imaging and magnetic resonance angiography of intracranial vessels. Following Smoker's criteria, the mean BA diameter plus 2 standard deviation defined ectasia. In addition, a location lateral to the lateral margin of the clivus of dorsum sellae or a bifurcation at the third ventricle floor or higher defined dolichosis. Associations between BA abnormalities and imaging markers of SVD were assessed by the use of regression models adjusted for demographics and cardiovascular risk factors. RESULTS: Of 346 participants, 11 (3.2%) had ectasia, 40 (11.6%) had dolichosis, and 47 (13.6%) had dolichoectasia (ectasia, dolichosis, or both). BA diameter was only associated with severity of white matter hyperintensities (P = .038). Dolichosis was associated with deep cerebral microbleeds (P = .002) but not with white matter hyperintensities. Dolichoectasia was associated with both white matter hyperintensities (P = .031) and cerebral microbleeds (P = .001). There were no associations with lacunar infarcts or enlarged perivascular spaces in any model. CONCLUSIONS: Prevalence of BA dolichoectasia in this rural setting is similar to that reported in other populations. Associations with imaging markers of SVD differ according to whether the subject has ectasia or dolichosis.

Higher Stroke Risk with Lower Blood Pressure in Hemodynamic Vertebrobasilar Disease: Analysis from the VERiTAS Study.

BACKGROUND: Despite concerns regarding hypoperfusion in patients with large-artery occlusive disease, strict blood pressure (BP) control has become adopted as a safe strategy for risk reduction of stroke. We examined the relationship between BP control, blood flow, and risk of subsequent stroke in the prospective Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study. METHODS: The VERiTAS study enrolled patients with recent vertebrobasilar (VB) transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion of vertebral or basilar arteries. Hemodynamic status was designated as low or normal based on quantitative magnetic resonance angiography. Patients underwent standard medical management and follow-up for primary outcome event of VB territory stroke. Mean BP during follow-up (<140/90 versus ≥140/90 mm Hg) and flow status were examined relative to subsequent stroke risk using Cox proportional hazards analysis. RESULTS: The 72 subjects had an average of 3.8 ± 1.2 BP recordings over 20 ± 8 months of follow-up; 39 (54%) had mean BP of<140/90 mm Hg. The BP groups were largely comparable for baseline demographics, risk factors, and stenosis severity. Comparing subgroups stratified by BP and hemodynamic status, we found that patients with both low flow and BP <140/90 mm Hg (n = 10) had the highest risk of subsequent stroke, with hazard ratio of 4.5 (confidence interval 1.3-16.0, P = .02), compared with the other subgroups combined. CONCLUSIONS: Among a subgroup of patients with VB disease and low flow, strict BP control (BP <140/90) may increase the risk of subsequent stroke.

Cerebellar cortical infarct cavities and vertebral artery disease.

INTRODUCTION: Cerebellar cortical infarct cavities are a newly recognised entity associated with atherothromboembolic cerebrovascular disease and worse physical functioning. We aimed to investigate the relationship of cerebellar cortical infarct cavities with symptomatic vertebrobasilar ischaemia and with vascular risk factors. METHODS: We evaluated the MR images of 46 patients with a recent vertebrobasilar TIA or stroke and a symptomatic vertebral artery stenosis ≥50 % from the Vertebral Artery Stenting Trial (VAST) for the presence of cerebellar cortical infarct cavities ≤1.5 cm. At inclusion in VAST, data were obtained on age, sex, history of vertebrobasilar TIA or stroke, and vascular risk factors. Adjusted risk ratios were calculated with Poisson regression analyses for the relation between cerebellar cortical infarct cavities and vascular risk factors. RESULTS: Sixteen out of 46 (35 %) patients showed cerebellar cortical infarct cavities on the initial MRI, and only one of these 16 patients was known with a previous vertebrobasilar TIA or stroke. In patients with symptomatic vertebrobasilar ischaemia, risk factor profiles of patients with cerebellar cortical infarct cavities were not different from patients without these cavities. CONCLUSION: Cerebellar cortical infarct cavities are seen on MRI in as much as one third of patients with recently symptomatic vertebral artery stenosis. Since patients usually have no prior history of vertebrobasilar TIA or stroke, cerebellar cortical infarct cavities should be added to the spectrum of common incidental brain infarcts visible on routine MRI.

Basilar artery diameter is an independent predictor of incident cardiovascular events.

OBJECTIVE: Basilar arterial (BA) dolichoectasia is associated with cerebral small-vessel disease and stroke. However, the association between moderate dilation of the BA and cerebral small-vessel disease or subsequent cardiovascular events remains unclear. This study aims to clarify the factors related to BA diameter and to clarify whether the BA diameter is an independent predictor of cardiovascular events. APPROACH AND RESULTS: The study subjects comprised 493 outpatients with atherosclerotic risk factors. BA diameter, lacunar infarct, severity of deep white matter hyperintensities, and intracranial steno-occlusive lesions were assessed with MRI and magnetic resonance angiography. Then, we prospectively evaluated the association between BA diameter and cardiovascular events. The BA diameter ranged from 1.1 to 5.2 mm, and only 0.8% of the patients had dolichoectasia. Male sex, the presence of lacunar infarcts, the severity of deep white matter hyperintensities, the fetal-type variation of the circle of Willis, and intracranial steno-occlusive lesions were independently associated with BA diameter. In the mean follow-up of 6.0 years, 91 patients developed cardiovascular events. BA diameter was independently associated with total cardiovascular events after adjusting for age, sex, and conventional risk factors (hazard ratio, 1.55 per 1 mm increase in BA diameter; P=0.009). CONCLUSIONS: Increased BA diameter within the normal range is related to both large-vessel disease and cerebral small-vessel disease, and it could be a new predictor of cardiovascular events.

Outcome predictors in acute basilar artery occlusion.

OBJECTIVE: to identify predictors of good outcome in acute basilar artery occlusion (Bao). Background: acute ischemic stroke (aiS) caused by Bao is often associated with a severe and persistent neurological deficit and a high mortality rate. METHODS: the set consisted of 70 consecutive aiS patients (51 males; mean age 64.5 ± 14.5 years) with Bao. the role of the following factors was assessed: baseline characteristics, stroke risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, estimated time to therapy procedure initiation, treatment method, recanalization rate, change in neurological deficit, post-treatment imaging findings. 30- and 90-day outcome was assessed using the modified rankin scale with a good outcome defined as a score of 0­ 3. RESULTS: the following statistically significant differences were found between patients with good versus poor outcomes: mean age (54.2 vs. 68.9 years; p=0.0001), presence of arterial hypertension (52.4% vs. 83.7%; p=0.015), diabetes mellitus (9.5% vs. 55.1%; p=0.0004) and severe stroke (14.3% vs. 65.3%; p=0.0002), neurological deficit at time of treatment (14.0 vs. 24.0 median of national institutes of health Stroke Scale [nihSS] points; p=0.001), successful recanalization (90.0% vs. 54.2%; p=0.005), change in neurological deficit (12.0 vs. 1.0 median difference of nihSS points; p=0.005). Stepwise binary logistic regression analysis identified age (or=0.932, 95% Ci=0.882­0.984; p=0.012), presence of diabetes mellitus (or=0.105, 95% Ci=0.018-0.618; p=0.013) and severe stroke (or=0.071, 95% Ci=0.013-0.383; p=0.002) as significant independent negative predictors of good outcome. CONCLUSIONS: in the present study, higher age, presence of diabetes mellitus and severe stroke were identified as significant independent negative predictors of good outcome.

Prevalence of intracranial large artery stenosis and occlusion in patients with acute ischaemic stroke or TIA.

Intracranial large artery stenosis and occlusion disease has been considered to be the cause of 8­10 % of ischaemic strokes in North America, and 30­50 % of strokes and more than 50 % of transient ischaemic attacks in Chinese population. So far we do not know the real prevalence of intracranial disease (ID) and the distribution of its risk factors in European population. We aimed to determine the prevalence and risk factors of ID in a European stroke population with computed tomography angiography (CTA). A retrospective study of consecutive ischaemic patients at the Stroke Unit of Utrecht, The Netherlands, from September 2006 to August 2008 was conducted. We assessed the presence of occlusion and/or stenosis of intracranial Internal Carotid Artery (ICA) and Middle Cerebral Artery on post-contrast 30-mm reconstruction axial CTA images. We analyzed the proportion of patients with ID, and the association of ID with risk factors and stroke subtype. In 220 patients (187 with stroke, 33 with TIA; mean age was 65 years, 57.3 % were male), intracranial stenosis was found in 6.4 % (95 % CI 3.9­10.4), intracranial occlusion in 34.5 % (95 % CI 28.6­41.0), and both occlusion and stenosis in 2.3 % (95 % CI 1.0­5.2). Multivariate analysis showed that the variables independently associated with ID were: extracranial ICA atherosclerosis (OR, 24.64; 95 % CI 6.30­96.38) and stroke subtypes TACS­PACS (OR, 7.61; 95 % CI 3.31­17.49). In conclusion, prevalence of intracranial stenosis in our study may well be consistent with previous observations in European and non-European population. ID may have been an underestimated condition in ischaemic Caucasian population.

Retrospective Cohort Angiographic Analysis of Vertebral Artery Dominance, Stenosis Patterns, and Demographic Correlations.

Background: Differences in dominance and stenosis in the complex vertebral artery (VA) network pose challenges in diagnosing and treating cerebrovascular diseases crucial for brain nutrition. This research examines these intricacies, highlighting the importance of detailed diagnosis and treatment methods. Objective: To analyze the prevalence of the dominant VA, evaluate the influence of gender and age on steno-occlusion, and explore the correlation between the dominant VA and stenosed VA segments. Methods: A retrospective study of 249 angiograms from patients with VA stenosed at King Abdullah University Hospital between August 2019 and December 2022. The patients presenting symptoms of vertigo, migraines, headaches, or transient ischemic attacks (TIA) were included, 182 cases were classified based on VA dominance and stenosis severity. The data were analyzed using IBM SPSS 27. Results: Out of the 182 participants, 64.8% were male, with an average age of 61.3 years and 35.2% were female. The prevalence of stenosis was distributed as follows: 26.4% mild, 44.0% moderate, and 29.7% severe. Statistically significant correlations were observed between hypertension, smoking, hyperlipidemia, and the degree of stenosis (p < 0.05), but not with diabetes. The prevalence of left vertebral artery (VA) dominance was found to be 41.1%. Additionally, there was no gender connection observed in the distribution of steno-occlusion (p = 0.434). There is no notable correlation between the degree of stenosis and the dominant vertebral artery (p > 0.05). Conclusion: Angiographic findings reveal the complex relationship between the dominance of the VA, patterns of stenosis, and demographic factors. Individuals with a dominant VA had a greater likelihood of developing stenosis on the opposite non-dominant side. The high occurrence of severe stenosis highlights the need for tailored diagnostic and treatment approaches. Understanding vertebral stenosis as a multifaceted interaction of demographic, lifestyle, and anatomical variables is essential for enhancing treatment strategies.

Prevalence of basilar artery dolichoectasia in patients with acute ischemic stroke or transient ischemic attack in a single center of Spain. / Prevalencia de la dolicoectasia de la arteria basilar en pacientes con ictus isquémico agudo o ataque isquémico transitorio en un centro español.

INTRODUCTION: Basilar artery dolichoectasia (BADE) refers to abnormal enlargement or displacement of the basilar artery (BA). The previously reported prevalence of BADE among patients with stroke is 0.3 to 33.1%, however, it might vary among studied populations. We aim is to determine the prevalence of BADE in patients presenting with acute ischemic stroke (AIS) or transient ischemic attack (TIA) in a Stroke Unit in a single center in Spain. PATIENTS AND METHODS: Patients 50 years old or older presenting with AIS or TIA were eligible for inclusion. Demographic and clinical data were prospectively collected. Two neuroradiologists, blind to each other, assessed BA morphology. RESULTS: Among 126 patients, 34.1% fulfilled the criteria for BADE (ectasia or dolichosis). BADE was associated with advanced age (p = 0.04). Patients with fetal-type circle of Willis presented smaller BA diameters (2.9 ± 0.1 vs. 3.5 ± 0.1; p < 0.001), whereas patients with lacunar strokes presented a greater diameter than other stroke subtypes (3.8 ± 0.3 mm vs. 3.3 ± 0.1 mm; p = 0.04). DISCUSSION AND CONCLUSIONS: In this single-center study of patients presenting with AIS or TIA, the prevalence of BADE (ectasia or dolichosis) is high. Further studies focusing on Spaniards should confirm our results.

TITLE: Prevalencia de la dolicoectasia de la arteria basilar en pacientes con ictus isquémico agudo o ataque isquémico transitorio en un centro español.Introducción. La dolicoectasia de la arteria basilar (DEAB) es un término que se refiere a la dilatación o elongación anormal de la arteria basilar (AB). La prevalencia de DEAB notificada hasta la fecha en pacientes con ictus es del 0,3 al 33,1%; sin embargo, puede variar entre poblaciones. Se propuso determinar la prevalencia de DEAB en pacientes con ictus isquémico agudo (IIA) o ataque isquémico transitorio (AIT) en una unidad de ictus de España. Pacientes y métodos. Se consideró a pacientes de 50 años o más con IIA o AIT para ser incluidos. La información demográfica y clínica se obtuvo de forma prospectiva. Dos neurorradiólogos evaluaron la morfología de la AB de forma independiente. Resultados. De 126 pacientes, el 34,1% cumplió los criterios de DEAB (ectasia o dolicosis). La DEAB se asoció a mayor edad (p = 0,04). Los pacientes con la variante fetal del polígono de Willis presentaron menor diámetro de la AB (2,9 ± 0,1 frente a 3,5 ± 0,1; p < 0,001), mientras que pacientes con ictus lacunar presentaron diámetros mayores de la AB que otros subtipos de ictus (3,8 ± 0,3 mm frente a 3,3 ± 0,1 mm; p = 0,04). Discusión y conclusiones. En este estudio de centro único de pacientes con IIA o AIT, la prevalencia de DEAB (ectasia o dolicosis) fue alta. Estudios futuros enfocados en población española podrían confirmar nuestros resultados.