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.

Comparative effectiveness of Ginkgo injections for treating vertebrobasilar insufficiency: A systematic review and network meta-analysis.

WHAT IS KNOWN AND OBJECTIVE: This study sought to assess the clinical effectiveness of Ginkgo injections (GIs) combined with conventional drugs for vertebrobasilar insufficiency (VBI). METHODS: Randomized controlled trials (RCTs) that assessed the adjunctive effects of GIs for patients with VBI were retrieved from several English and Chinese databases from inception to December 2018. The Cochrane risk of bias method was used to evaluate the methodological quality of the eligible trials. The data were analysed by Stata 13.0 and WinBUGS 1.4.3 software. RESULTS: A total of 20 RCTs that included 1710 patients were included. All RCTs had an unclear risk of bias or a high risk of bias. The network meta-analysis (NMA) showed that the use of four kinds of GIs, especially Ginkgo leaf extract and dipyridamole injections (GDs), as adjunctive therapies with drugs for VBI increased the total effectiveness rate. Ginkgo biloba leaf extract injections (EGbs) combined with conventional drugs were more effective than only conventional drugs for improving the results of transcranial Doppler ultrasonography (TCD). Shuxuening injections (SXNs) seemed superior for improving blood viscosity-related indicators. Adverse events were mentioned in nine trials, and there was no difference between the GI group and the control group for the incidence rate of adverse events. WHAT IS NEW AND CONCLUSIONS: GIs showed significant benefits as an add-on therapy for VBI, as GIs increased the total effectiveness rate and improved the results of TCD examinations. Due to the limited sample size and quality of the included trials, the results of this review still need to be tested in larger, rigorous studies in the future.

The effect of chinese herbal medicine Banxia Baizhu Tianma Decoction for the treatment of vertebrobasilar insufficiency vertigo: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: Banxia Baizhu Tianma Decoction (BBTD) is widely used to treat vertebrobasilar insufficiency vertigo (VBIV) in China, but its efficacy remains largely unexplored. We systemically summarized relevant evidence from randomized controlled trials (RCTs) to assess the therapeutic effect of BBTD. METHODS: Seven electronic databases were searched for relevant electronic studies published before July 2016. We evaluated RCTs that compared BBTD, anti-vertigo drugs and a combination of BBTD and anti-vertigo drugs. We performed a meta-analysis in accordance with the Cochrane Collaboration criteria. The outcomes were clinical efficacy (CE), blood flow velocity of the vertebrobasilar artery by transcranial Doppler (TCD), and adverse effects. RESULTS: Twenty-seven studies with a total of 2796 patients were identified. Compared with anti-vertigo drugs, BBTD showed slight effects on CE (n=350; RR, 1.09; 95% CI, 1.01-1.18; p=0.03; I2=0%); however, BBTD plus anti-vertigo drugs (BPAD) significantly improved the clinical efficacy (n=2446; RR, 1.20; 95% CI, 1.16-1.24; p<0.00001; I2=0%) and accelerated the blood flow velocity of the left vertebral artery (LVA) (n=1444; WMD, 5.21cm/s; 95% CI, 3.72-6.70cm/s; p<0.00001; I2=91%), the blood flow velocity of the right vertebral artery (RVA) (n=1444; WMD, 5.45cm/s; 95% CI, 4.02-6.88cm/s; p<0.00001; I2=89%), and the blood flow velocity of the basilar artery (BA) (n=1872; WMD, 5.20cm/s; 95% CI, 3.86-6.54cm/s; p<0.00001; I2=90%). Adverse effects were mentioned in six studies. CONCLUSIONS: The current evidence indicates that BPAD is effective for the treatment of VBIV, but the efficacy and safety of BBTD is uncertain because of the limited number of trials and low methodological quality. Hence, high-quality and adequately powered RCTs are warranted.

Relevance of the Pharmacokinetic and Pharmacodynamic Profiles of Puerariae lobatae Radix to Aggregation of Multi-Component Molecules in Aqueous Decoctions.

The complexity of traditional Chinese medicines (TCMs) is related to their multi-component system. TCM aqueous decoction is a common clinical oral formulation. Between molecules in solution, there exist intermolecular strong interactions to form chemical bonds or weak non-bonding interactions such as hydrogen bonds and Van der Waals forces, which hold molecules together to form "molecular aggregates". Taking the TCM Puerariae lobatae Radix (Gegen) as an example, we explored four Gegen decoctions of different concentration of 0.019, 0.038, 0.075, and 0.30 g/mL, named G-1, G-2, G-3, and G-4. In order of molecular aggregate size (diameter) the four kinds of solution were ranked G-1 < G-2 < G-3 < G-4 by Flow Cell 200S IPAC image analysis. A rabbit vertebrobasilar artery insufficiency (VBI) model was set up and they were given Gegen decoction (GGD) at a clinical dosage of 0.82 g/kg (achieved by adjusting the gastric perfusion volume depending on the concentration). The HPLC fingerprint of rabbit plasma showed that the chemical component absorption into blood in order of peak area values was G-1 < G-2 > G-3 > G-4. Puerarin and daidzin are the major constituents of Gegen, and the pharmacokinetics of G-1 and G-2 puerarin conformed with the two compartment open model, while for G-3 and G-4, they conformed to a one compartment open model. For all four GGDs the pharmacokinetics of daidzin complied with a one compartment open model. FQ-PCR assays of rabbits' vertebrobasilar arterial tissue were performed to determine the pharmacodynamic profiles of the four GGDs. GGD markedly lowered the level of AT1R mRNA, while the AT2R mRNA level was increased significantly vs. the VBI model, and G-2 was the most effective. In theory the dosage was equal to the blood drug concentration and should be consistent; however, the formation of molecular aggregates affects drug absorption and metabolism, and therefore influences drugs' effects. Our data provided references for the rational use of Chinese medicines in the clinic, such as the best oral preparation and decoction concentration.

Clinical research of persimmon leaf extract and ginkgo biloba extract in the treatment of vertebrobasilar insufficiency.

This paper aims to compare the curative effects of persimmon leaf extract and ginkgo biloba extract in the treatment of headache and dizziness caused by vertebrobasilar insufficiency. Sixty patients were observed, who underwent therapy with persimmon leaf extract and ginkgo biloba extract based on the treatment of nimodipine and aspirin. After 30 days, 30 patients treated with persimmon leaf extract and 30 patients with ginkgo biloba extract were examined for changes in hemodynamic indexes and symptoms, such as headache and dizziness. The results showed statistically significant differences of 88.3% for the persimmon leaf extract and 73.1% for the ginkgo biloba extract, P < 0.05. Compared to the group of ginkgo biloba extract, the group of persimmon leaf extract had more apparent improvement in the whole blood viscosity, plasma viscosity, fibrinogen, hematokrit, and platelet adhesion rate, and the difference was statistically significant (P < 0.05 or P < 0.01). Based on these analyses, it can be concluded that persimmon leaf extract is better than ginkgo biloba extract in many aspects, such as cerebral circulation improvement, cerebral vascular expansion, hypercoagulable state lowering and vertebrobasilar insufficiency-induced headache and dizziness relief.

Forty-six cases of vertebrobasilar insufficiency treated by acupuncture plus intravenous infusion of ligustrazine.

OBJECTIVE: To observe the therapeutic effect of acupuncture plus Ligustrazine on vertebrobasilar insufficiency (VBI) by transcranial Doppler (TCD) sonography. METHODS: 86 VBI patients including 56 cases of low flow rate velocity type (LFVT) and 30 cases of high flow velocity type (HFVT) were randomly divided into Ligustrazine group (26 LFRT and 14 HFVT) and acupuncture plus Ligustrazine group (30 LFVT and 16 HFVT). The blood flow velocity (BFV) of vertebral artery (VA) and basilar artery (BA) in systole before and after treatment was measured with TCD and therapeutic effects were evaluated after 10 days' treatment in the two groups. RESULTS: In the acupuncture plus Ligustrazine group, the total effective rate was 93.3% and 88.5% in cases of LFVT and HFVT respectively, and BFV of VA and BA increased in LFVT patients while that in HFVT patients decreased significantly (P<0.05 or P<0.01). CONCLUSION: Owing to its dual regulation on blood flow of VA and BA, the therapeutic effect of acupuncture plus Ligustrazine was better than that of simple Ligustrazine.

[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.

Recovery in a patient with locked-in syndrome.

BACKGROUND AND PURPOSE: Sildenafil citrate has been shown to enhance neurogenesis, angiogenesis, synaptogenesis, and neurological outcome by augmentation of cyclic guanosine monophosphate (cGMP) levels in animal models of ischemic stroke. Whether sildenafil citrate may be helpful for recovery in human stroke is unknown at this time. METHODS: A 41-year-old woman with locked-in syndrome due to pontine infarction began receiving 150 mg of oral sildenafil citrate daily on a compassionate use basis in August 2003 and continues treatment at this time. Magneto-encephalography (MEG) was performed at 12 and 17 months after stroke. RESULTS: No serious adverse events have occurred. Significant milestone recoveries including standing, use of both arms, talking, and full return of swallowing have occurred, particularly after nine months of treatment. The MEG showed a significantly increased amplitude in the somatosensory cortex. CONCLUSION: Daily use of high dose sildenafil citrate appears to be safe in this patient with stroke resulting in locked-in syndrome. Further studies will be required to establish safety and efficacy.

[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.

Possible short-term amelioration of basilar plaque by high-dose atorvastatin: use of reductase inhibitors for intracranial plaque stabilization.

Regression of symptomatic intracranial atherostenosis is not known to be a common occurrence. In this case, delay of basilar reconstruction by endovascular means permitted serial angiographic assessment of plaque change. The use of high-dose atorvastatin over a 2-week period was associated with marked angiographic improvement. Medical programs of plaque stabilization may provide adjunctive benefit in patients with symptomatic intracranial disease.

[The effect of gingko biloba on cochleovestibulary pathology of vascular origin]. / Efecto del Gingko biloba sobre la patología cocleovestibular de origen vascular.

The AA. of the present paper recall the clinical and functional results of this therapy in a group of 70 patients complaining of vertigo. The Gingko biloba extract (4 ml/12 h per mouth) has been continued during 6 months. Neck and vertebrobasilar insufficiency were predominant causes. Six months later statistically significant changes regarding the decrease of intensity of tinnitus and vertigo crises were confirmed. Besides favorable alterations in the peripherical symptomatology as a relative hearing improvement turned up.

[Clinical research on the treatment of cervical spondylosis with jingtongning granule].

The authors treated 102 cervical spondylosis patients with jing tong ning granule that made of herbs according to the TCM principle of promoting blood circulation to remove blood stasis. The 9 hemorheological indexes before and after treatment were observed. 15 patients of all were also observed the changes of eyeground microangium. Moreover, the animal experiments were taken in order to test and verify the effects further. The results revealed that the total effective rate was 96.1%. The main hemorheological indexes (eg. blood viscosity and plasma viscosity) showed significant difference in statistics before and after treatment (P less than 0.05, P less than 0.01). The changes of eyeground microangium had significant difference too, (P less than 0.01). The animal experimental results were the same as the clinical ones. Hence, the authors consider that jing tong ning granule had the effects to decrease the blood viscosity, improve microcirculation and accelerate blood flow.

[Dissections of the vertebral artery following cervical chiropractic manipulations]. / Dissektionen der Arteria vertebralis nach zervikalen chiropraktischen Manipulationen.

In a 37-year-old female patient complaining of increasing pain in the neck and occiput, chiropractic manipulations at the cervical vertebral column were associated with ischaemias of the brain stem presenting as vertigo, transient "locked-in" syndrome followed by vomiting, and sensorimotor hemiparesis. Digital subtraction angiography (DSA) revealed complete obstruction of the right and slight dissection of the left vertebral artery. The symptoms receded within a few days after heparinisation with 1000 IU/h intravenously. A 39-year-old female patient developed vertigo, nystagmus, tetraparesis and dysarthria two days after chiropractic intervention because of refractory pain in the neck and occiput. DSA showed embolism of the basilar artery and extensive dissections of the vertebral arteries. The basilar artery was completely recanalized after local intraarterial fibrinolysis with 50,000 IU urokinase. During the further course of treatment the symptoms receded under heparin and phenprocoumon over a period of 8 months, except for hemiparesis on the left side especially affecting the arm. Trivial traumas can result in dissections of the vertebral arteries. Severe neck pain is a frequent, typical early symptom. Hence, patients with cervical vertebral column syndromes should receive chiropractic treatment only after careful diagnosis.

Treatment of vertebrobasilar insufficiency. Use of calcium antagonists.

The influence of various calcium-entry blockers on the vestibular system was investigated. This paper reports results from animal experiments and also from clinical studies with Flunarizine and Nimodipine. An animal experimental model of vertebrobasilar insufficiency was developed. The effect of these drugs on vestibular nystagmus was studied in Alsatian dogs before and after occluding one vertebral artery. In order to analyse the influence of these drugs on the vestibular nystagmus and on the clinical symptoms in patients with vertebrobasilar insufficiency, different open and double-blind studies were performed.

Calcium entry blockers in the treatment of vertebrobasilar insufficiency.

The influence of different calcium entry blockers on the vestibular system was investigated. The paper reports results from animal experiments and also from clinical studies with flunarizine and nimodipine. An animal experimental model of vertebrobasilar insufficiency was developed. The effect of the two drugs on the vestibular nystagmus was studied in Alsatian dogs before and after occluding one vertebral artery. In order to analyze the influence of the drugs on the vestibular nystagmus and on the clinical symptoms in patients with vertebrobasilar insufficiency, different open and double-blind studies were performed.

[Calcium blockers in the therapy of vertebrobasilar insufficiency. Results of animal experiments and clinical studies]. / Kalzium-Blocker in der Therapie der vertebrobasilären Insuffizienz. Ergebnisse tierexperimenteller und klinischer Studies.

Vertebrobasilar insufficiency (VBI) is a clinical syndrome which includes different transient brain stem symptoms. In addition to anamnesis and clinical study electronystagmography (ENG) is regarded as the most important method for testing the labyrinthine and brain stem system. Typical findings, not only in patients with VBI, but also in animal experiments (occlusion of one vertebral artery) are an increase in nystagmus frequency and decrease in nystagmus amplitude. The present study concerns two calcium antagonists: flunarizine and nimodipine. During tests on patients the caloric and the rotatory nystagmus and during animal experiments the rotatory nystagmus was investigated. Patient tests as well as animal experiments showed, that flunarizine and nimodipine have a depressant influence on the pathologically increased nystagmus frequency. With both substances there was also a trend to normalization of nystagmus amplitude as well as an improvement of clinical symptoms.