Long-Term Outcomes After Stenting in Extracranial vs. Intracranial Stenosis.

Objective: The purpose of this pilot study is to explore the difference in safety and effectiveness after stenting in patients with extracranial or intracranial vertebral artery stenosis. Methods: The study involved 26 patients treated with stents for ≥70% stenosis between January 1, 2017, and September 8, 2020. The patients were divided into intracranial and extracranial groups based on the location of the target vessel stenosis. The incidence of stroke or death within 30 days, long-term recurrence of ischemic symptoms, and restenosis during follow-up were monitored. Results: Within 30 days, no stroke or death was observed in the 26 patients, During the follow-up period, the risk of recurrence of posterior circulation stroke or transient ischemic attack was 23.1% (6/26). Vascular-related complications were 5.6% vs. 12.5% (P = .529) in the intracranial vs. extracranial stenosis group. After 1 year, stroke or transient ischemic attack of posterior circulation was observed in 12.5% (1/8) vs. 16.7% (3/18) in the intracranial and extracranial stenosis group, respectively. The restenosis rate in the intracranial stenosis group was higher than the extracranial stenosis group (37.5% vs. 28.6%, P > .05). This trend was also found in the asymptomatic restenosis rate (25% vs. 7.1%, P = .527). Conclusions: The study results showed that there was no significant difference in the safety and effectiveness after stenting in extracranial and intracranial vertebral artery stenosis, but intracranial vertebral artery stenosis has a low rate of symptomatic restenosis. Symptomatic restenosis may be an important problem that limits the efficacy of extracranial vertebral artery stenting.

Chiropractic Management of Neck Pain Complicated by Symptomatic Vertebral Artery Stenosis and Dizziness.

BACKGROUND Vertebrobasilar insufficiency (VBI) is most often caused by vertebrobasilar atherosclerosis, often presenting with dizziness and occasionally neck pain. Little research or guidelines regarding management of neck pain in affected patients exists. CASE REPORT A 62-year-old male hypertensive smoker presented to a chiropractor with a 13-year history of insidious-onset neck pain, dizziness, and occipital headache with a Dizziness Handicap Inventory (DHI) of 52%. The patient had known VBI, caused by bilateral vertebral artery plaques, and cervical spondylosis, and was treated with multiple cardiovascular medications. The chiropractor referred patient to a neurosurgeon, who cleared him to receive manual therapies provided manual-thrust cervical spinal manipulative therapy (SMT) was not performed. The chiropractor administered thoracic SMT and cervicothoracic soft tissue manipulation. The neck pain and dizziness mostly resolved by 1 month. At 1-year follow-up, DHI was 0%; at 2 years it was 8%. A literature search revealed 4 cases in which a chiropractor used manual therapies for a patient with VBI. Including the present case, all patients had neck pain, 60% had dizziness, and all were treated with SMT either avoiding manual cervical manipulation altogether or modifying it to avoid or limit cervical rotation, yielding positive outcomes. CONCLUSIONS The present and previous cases provide limited evidence that some carefully considered chiropractic manual therapies can afford patients with VBI relief from concurrent neck pain and possibly dizziness. Given the paucity of research, cervical SMT cannot be recommended in such patients. These findings do not apply to vertebral artery dissection, for which SMT is an absolute contraindication.

A novel exaggerated "spino-bulbo-spinal like" reflex of lower brainstem origin.

BACKGROUND: Many different oligosynaptic reflexes are known to originate in the lower brainstem which share phenomenological and neurophysiological similarities. OBJECTIVE: To evaluate and discuss the differences and aberrancies among these reflexes, which are hard to discern clinically using neurophysiological investigations with the help of a case report. METHODS: We describe the clinical and neurophysiological assessment of a young man who had a childhood history of opsoclonus-myoclonus syndrome with residual mild ataxia and myoclonic jerks in the distal extremities presenting with subacute onset total body jerks sensitive to sound and touch (in a limited dermatomal distribution), refractory to medications. RESULTS: Based on clinical characteristics and insights gained from neurophysiological testing we could identify a novel reflex of caudal brainstem origin. CONCLUSIONS: The reflex described is likely an exaggerated normal reflex, likely triggered by a dolichoectatic vertebral arterial compression and shares characteristics of different reflexes known to originate in caudal brainstem, which subserve distinctive roles in human postural control.

Acute Basilar Artery Occlusion: Differences in Characteristics and Outcomes after Endovascular Therapy between Patients with and without Underlying Severe Atherosclerotic Stenosis.

BACKGROUND AND PURPOSE: Prediction of underlying intracranial atherosclerotic stenosis before endovascular therapy might be helpful for appropriate therapeutic planning in patients with acute ischemic stroke. This study aimed to compare the characteristics and treatment outcomes in patients with acute basilar artery occlusion relative to the existence or nonexistence of underlying intracranial atherosclerotic stenosis. MATERIALS AND METHODS: Sixty-two patients with acute basilar artery occlusion underwent multimodal endovascular therapy. All patients underwent stent-retriever thrombectomy as a first-line endovascular therapy. Patients with underlying intracranial atherosclerotic stenosis underwent additional intracranial angioplasty and stent placement. The clinical and imaging characteristics and treatment outcomes were retrospectively analyzed and compared between patients with and without intracranial atherosclerotic stenosis. RESULTS: Underlying intracranial atherosclerotic stenosis was identified at the occlusion site in 15 patients (24.1%). Occlusion in the proximal segment of the basilar artery was more common in patients with intracranial atherosclerotic stenosis (60% versus 6.4%, P < .001), whereas occlusion in the distal segment was more common in those without it (91.5% versus 26.7%, P < .001). Bilateral thalamic infarction on a pretreatment DWI was less common in patients with intracranial atherosclerotic stenosis (0% versus 27.7%, P = .027) compared with those without it. There were no significant differences in the rates of successful revascularization, favorable outcome, symptomatic hemorrhage, and mortality between the 2 groups. CONCLUSIONS: Underlying intracranial atherosclerotic stenosis was not uncommon in patients with acute basilar artery occlusion. The occlusion segment of the basilar artery and the presence or absence of bilateral thalamic infarction on a pretreatment DWI might be helpful for predicting underlying intracranial atherosclerotic stenosis in patients with acute basilar artery occlusion. Patients with and without underlying intracranial atherosclerotic stenosis who underwent endovascular therapy had similar outcomes.

Basilar stroke from a persistent hypoglossal artery.

Occlusion of the basilar artery can be treated with endovascular thrombectomy, although the results have not been well studied. Persistent fetal cerebrovascular anatomy can lead to unusual presentation of carotid atherosclerotic disease and can be a barrier to successful mechanical thrombectomy if not recognized. This case presents a rare persistent carotico-basilar anastomosis which resulted in basilar occlusion via the persistent hypoglossal artery and coincident absence of contralateral vertebral arterial access due to a left vertebral artery terminating in the left posterior inferior cerebellar artery. Preoperative recognition of this anatomy afforded by review of cross-sectional imaging was critical to success during this emergent procedure.

Varicella zoster virus vasculopathy: a treatable form of rapidly progressive multi-infarct dementia after 2 years' duration.

We describe an extraordinarily protracted case of varicella zoster virus (VZV) multifocal vasculopathy in a man who presented initially with ischemic optic neuropathy and then suffered 4 episodes of stroke manifesting as multi-infarct dementia over a 2-year period. Brain magnetic resonance imaging (MRI) and angiography (MRA) revealed cortical and subcortical infarctions as well as vasculitic occlusion and stenosis. The patient was treated with corticosteroids and later with cyclophosphamide. More than 2 years after the onset of neurological disease, two cerebrospinal fluid (CSF) examinations revealed the presence of anti-VZV IgG antibody with reduced serum-to-CSF ratios of anti-VZV IgG compared with ratios for total IgG and albumin, indicative of intrathecal synthesis of anti-VZV IgG. After definitive diagnosis, immunosuppressive drugs were discontinued and he was treated with intravenous acyclovir; both mental status and gait improved and no further episodes of neurological dysfunction ensued. The favorable outcome in this patient indicates that VZV vasculopathy can be treated successfully even after 26 months. VZV must be considered as a possible cause of neurological disease in any patient with idiopathic multifocal vasculopathy.

[Effect of reflex therapy on the dynamics of cognitive impairment in patients with chronic vertebrobasilar insufficiency].

Effectiveness of reflex therapy on the dynamics of cognitive impairment was assessed during the observation and treatment of 77 patients with chronic vertebrobasilar insufficiency. The inclusion of acupuncture and biodynamic correction in the complex therapy of patients with chronic vertebrobasilar insufficiency increases the effectiveness of integrated treatment compared with conventional therapy that was confirmed by neuropsychological studies of patients with discirculatory encephalopathy caused by vertebral pathology.

[Penetrating needling on head points for vertigo caused by vertebral-basilar arterial blood-supply insufficiency].

OBJECTIVE: To observe the differences in therapeutic effect between penetrating needling on head points and acupuncture of syndrome division in the treatment of vertigo caused by vertebral-basilar arterial blood-supply insufficiency. METHODS: Sixty cases of vertigo caused by vertebral-basilar arterial blood-supply insufficiency were divided into 2 groups: a penetrating needling on head points group (group A) and an acupuncture of syndrome division group (group B), 30 cases in each one. In group A, penetrating needling technique was applied from Baihui (GV 20) towards Qianding (GV 21), Shuaigu (GB 8) towards Qubin (GB 7) and Yuzhen (BL 9) towards Tianzhu (BL 10). Electric stimulation was added. In group B, the acupoints were selected according to syndromes. For example, upper disturbance of wind yang: Ganshu (BL 18), Xingjian (LR 2),etc. were selected; upper disturbance of turbid phlegm: Yinlingquan (SP 9), Fenglong (ST 40), etc. were selected; qi and blood deficiency: Baihui (GV 20), Xuehai (SP 10), etc. were selected; liver and kidney yin deficiency: Ganshu (BL 18), Shenshu (BL 23), etc. were selected. Electric stimulation and needling manipulation were conducted on those acupoints. Ten treatments made one session. After continuous 2 sessions of treatment, the efficacy, symptom score and physical sign score were compared between two groups. Transcranial Doppler (TCD) examination was done to observe hemodynamic changes of anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery (PCA) before and after treatment. RESULTS: The total effective rate in group A was 96.7% (29/30) that was obviously better than 83.3% (25/30) in group B (P<0.05). The scores of vertigo degree, vertigo frequency, duration and accompanied symptoms after treatment were lower obviously as compared with those before treatment in two groups (all P<0.05). The improvements in group A were much significant (all P<0.05). The highest mean velocity(Vm) of bilateral MCA, ACA and PCA were apparently reduced after treatment in two groups (P< 0.05, P<0.01). The improvements in group A were much more apparently (all P<0.05). CONCLUSION: The penetrating needling on head points can effectively relieve vertigo caused by vertebral-basilar arterial blood-supply insufficiency, reduce the attack frequency and improve in its accompanied symptoms. Its clinical efficacy is significantly superior to that in acupuncture of syndrome division group.

Topographic patterns of thalamic infarcts in association with stroke syndromes and aetiologies.

OBJECTIVE: To characterise the topographic patterns of thalamic infarcts associated with various stroke syndromes and aetiologies. METHODS: In this study, 168 consecutive patients with acute infarcts involving the thalamus were investigated by use of diffusion weighted MR imaging. Involved thalamic territories were classified into four vascular territories: anterior (polar artery), posteromedial (thalamoperforating artery), ventrolateral (thalamogeniculate artery) and posterolateral (posterior choroidal artery) territory. The distribution of thalamic infarcts involving specific vascular territories in association with various stroke syndromes and aetiologies were analysed. RESULTS: There was a significant association between involvement of the ventrolateral thalamus and isolated thalamic infarcts (49 patients (73%), p<0.01) or posterior cerebral artery infarcts (29 patients (76%), p=0.02), and between involvement of the posteromedial thalamus and top of the basilar artery syndrome (17 patients (77%), p<0.001) or extended posterior circulation infarcts (29 patients (71%), p<0.001). The ventrolateral territory was most commonly affected in association with small vessel disease (43 patients (72%), p=0.03) and the posteromedial territory in association with large artery disease (19 patients (63%), p<0.01). In cardioembolic stroke, the ventrolateral, posteromedial and posterolateral territories were equally affected. CONCLUSIONS: The results of the present study indicate a specific association between the topographic patterns of thalamic infarcts and the stroke syndromes and aetiologies.

Severe hyperthermia caused by four-vessel occlusion of main cerebral arteries.

We present the case of a comatose patient with acute large infarction of posterior cerebral and cerebellar areas and severe hyperthermia (max. 40.4 degrees C). Angiography demonstrated four-vessel occlusion of the main cerebral arteries, suggesting the possibility that both internal carotid and left vertebral arteries were already occluded and he became unconscious following additional occlusion of the right vertebral artery. Autopsy findings revealed bilateral ischemic damage of the hypothalamus in addition to the above infarct areas. Sudden ischemic involvement of both hypothalamic regions may have caused the extremely high fever in this case.

Fifty cases of vertebrobasilar ischemic vertigo treated by acupuncture.

OBJECTIVE: To observe the therapeutic effects of filiform needle acupuncture combined with dermal needle tapping for vertebrobasilar ischemic vertigo. METHODS: Based on the etiopathogenesis of TCM, the disease is caused by turbid phlegm clouding the heart orifice combined with wind, leading to insufficient nourishment of the brain due to deficiency of blood. Fenglong (ST 40) was punctured with filiform needle to resolve phlegm; Fengchi (GB 20) to dispel wind; Baihui (GV 20) to stop dizziness; and Lieque (LU 7) to widen the inner diameter of the vertebral arteries and increase peak systolic velocity and minute blood flow volume, so as to improve blood supply to the vertebral arteries. Dazhui (GV 14) was stimulated by tapping with a dermal needle to improve blood supply to the head. RESULTS: Of 50 patients in this series, 39 cases (78%) were cured, 6 cases (12%) relieved, 4 cases (8%) improved, and 1 case (2%) failed, with a total effective rate of 98%. CONCLUSION: Acupuncture combined with dermal needle tapping is an effective therapy for treating vertebrobasilar ischemic vertigo.

[Clinical observation on Qingling Dingxuan Decoction in treating vertigo cause by insufficient blood-supply of ventebrobasilar artery].

OBJECTIVE: To observe the therapeutic effect of Qingling Dingxuan Decoction (QDD) on vertigo caused by insufficient blood-supply of ventebrobasilar artery (IBVA). METHODS: Thirty-nine patients were divided into the flunarizine group (n=19) and the QDD group (n=20) treated with respective medicine on the base of routine treatment with Chinese and Western medicine. The clinical efficacy and recurrent rate were observed and compared. RESULTS: Compared with those in the flunarizine group, clinical curative effect was better, recurrent rate lower, symptom score higher, hemorheological parameters and transcranial doppler indexes were improved more significant in the QDD group (P < 0.01 or P < 0.05). CONCLUSION: QDD had obvious therapeutic effect on IBVA. Improvement of microcirculation and reduction of blood viscosity may be one of the therapeutical mechanisms.

[Idiopathic thunderclap headache: reversible vasospasm of the Arteria basilaris]. / Primärer Donnerschlagkopfschmerz: Reversibler Vasospasmus der Arteria basilaris.

Thunderclap headache describes a rare headache syndrome characterized by abrupt-onset severe headache mimicking subarachnoidal bleeding, which has to be excluded by adequate diagnostic procedures such as digital subtraction angiography. The pathophysiology is still not clear but there are an increasing number of reports which describe some kind of vasospasm of the intracranial arteries during the headache episode. Here we describe a patient with a thunderclap headache and a mid-basilar narrowing due to a reversible vasospasm.

[A clinical study on the effect of Yinxing Damo combined with betahistine hydrochloride injection on vertebral basilar artery ischemic vertigo].

OBJECTIVE: To evaluate the therapeutic efficacy of Yinxing Damo (YXDM) combined with Betahistine Hydrochloride Injection (BHI) on vertebra basilar artery ischemic vertigo (VBIV). METHODS: Ninety patients with VBIV were randomly divided into two groups; 45 patients (the treated group) were treated with YXDM and BHI intravenous dripping, once a day for 14 days. Another 45 patients (control group) were treated with Xueshuantong and BHI intravenous dripping, once daily for 14 days. The clinical syndromes and the index of the transcranial Doppler (TCD) and hemorheology were observed. RESULTS: The total effective rate was 100% in the treated group, which was better than that in the control group 90.5%, (P < 0.05). The indexes of TCD and hemorheology in the treated group were obviously improved after treatment, (P < 0.01). CONCLUSION: YXDM combined with BHT injection had better effect in treating patients with VBIV is an ideal drug for VBIV.

[Clinico-neurological and stabilometric analysis of betahistine (betaserc) efficacy in the patients with vertigo in the rehabilitation period of ischemic stroke].

A study of betahistine (betaserc) in 65 patients aged 59,48 +/- 8,63 years with vertigo in early rehabilitation period of ischemic stroke has been carried out. Thirty-five patients got atiplatelet and antihypertensive therapy and were also treated by betaserc--8-16 mg 3 times per day for 14 days per os, after meals. The control group of 30 patients received only atiplatelet and antihypertensive therapy. Both groups were similar in demographic and clinical characteristics. The treatment with betahistine reduced the intensity and duration of vertigo, led to improvement of coordination and equilibrium, increase stability of a vertical posture that was accompanied by significant (p<0,05) improvement of the values on the Hoffenberth and Bohannon scales. Betahistine treatment also resulted in marked authentic (p<0,05) improvement of stabilometric parameters in biological feedback task that might be explained by activation of the mechanisms maintaining vertical balance. An improvement of clinical and neurophysiologic traits was more pronounced in the group treated with betaserc as compared to the control group.

[EHF-puncture in combined rehabilitation of children with vertebrobasilar insufficiency syndrome in spinal deformities]. / KVCh-punktura v kompleksnoi reabilitatsii detei s syndromom vertebrobaziliarnoi nedostatochnosti pri deformatsiiakh pozvonochnika.

The results were compared of different programs of rehabilitation in 45 patients aged 5 to 18 years with spinal deformities and vertebrobasilar failure. Control patients received only basic therapy, the study group received also EHF-puncture. The efficacy of rehabilitation was confirmed by electropuncture diagnosis and rheoencephalogram. The patients with high tonicity of small vessels demonstrated a significantly improved regional circulation. This favours differential use of EHF puncture in the complex of rehabilitative measures.

Severe bruxism following basal ganglia infarcts: insights into pathophysiology.

Bruxism characterized by clenching and grinding of teeth can lead to toothwear, headaches and depression. While bruxism has been associated with a number of neurological diseases, it has not been highlighted following cerebral infarction. An elderly man presented with an acute onset of tooth grinding and jaw clenching associated with dysarthria. His bruxism was worse during the day and resolved during sleep. He had frequent jaw aches, headaches and swallowing difficulty. Examination demonstrated the presence of dysarthria with jaw clenching and tooth grinding, producing persistent high pitch and loud squeaky sounds. A magnetic resonance imaging and angiography examination revealed a recent infarct in the right thalamus. In addition, chronic lacunar infarcts were present in the bilateral caudate nuclei with severe basilar artery stenosis. He was successfully treated with botulinum toxin. We discuss the pathophysiologic mechanisms of bruxism associated with basal ganglia infarcts. Dysfunction of the efferent and/or afferent thalamic or striatopallidal tracts may play a role in bruxism. Early recognition of bruxism following stroke could reduce unnecessary suffering since the condition can be effectively treated.