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

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

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

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

Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options.

INTRODUCTION: Stump syndrome is defined as a clinical syndrome resulting from a distal intracranial vessel embolic stroke due to an extracranial vessel occlusion. Similar to the anterior circulation, the recurrence of ischemic strokes in territories supplied by the posterior circulation in the presence of vertebral artery occlusion is termed Vertebral Artery Stump Syndrome (VASS). MATERIAL AND METHODS: We conducted a literature review, identifying 72 patients with transient ischemic attacks (TIAs) or ischemic strokes attributed to VASS, according to Kawano criteria. We categorized all patients in two groups focusing on the therapeutic management those who underwent primary medical treatment and those who received endovascular or surgical treatment either in acute or chronic phase. RESULTS: In the anticoagulant therapy group, only 1 patient had a stroke recurrence. Among the 4 on antiplatelets, all had recurrences, but 3 benefited from switching to anticoagulants or endovascular therapy. In the endovascular therapy group, worse outcomes were linked to acute large vessel occlusion. Endovascular treatment of the vertebral artery, in a chronic phase, was explored in literature for recurrent TIAs or minor strokes suggesting that this could be a viable therapeutic alternative when medical treatment failed in preventing recurrence of ischemic stroke. CONCLUSIONS: Some studies suggest that anticoagulant medical therapy may be beneficial for VASS and endovascular therapy has also been reported for selected patients. However, data on treatment outcomes and prognosis are still underreported, making treatment decisions challenging. Randomized Controlled Trials are needed to establish the optimal treatment approach.

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.

Relationship of inter-arm systolic blood pressure difference with subclavian artery stenosis and vertebral artery stenosis in patients undergoing carotid endarterectomy

Abstract Introduction: The aim of this study was to examine the association of inter-arm systolic blood pressure difference (IASBPD) with carotid artery stenosis, subclavian artery stenosis and vertebral artery stenosis in patients who underwent carotid endarterectomy. Methods: A total of 141 patients (29 females, 112 males; mean age 71.2±10.4 years; range 47 to 92 years) who underwent carotid endarterectomy between September 2010 and December 2017 were retrospectively evaluated. We classified patients into four groups according to the IASBPD ˂ 10 mmHg, ≥ 10 mm Hg, ≥ 20 mmHg and ≥ 30 mmHg. The stenosis of both subclavian and vertebral arteries was considered as ≥ 50%. Results: Of the 141 patients, 44 (31.2%) had ≥ 10 mmHg, 29 (20.5%) had ≥ 20 mmHg and 4 (2.8%) had ≥ 30 mmHg of IASBPD. 26 patients (18.4%) were diagnosed with significant subclavian artery stenosis and 18 (69.2%) of them had more than 20 mmHg of IASBPD. Of the 29 patients with IASBPD ≥ 20 mmHg, 19 patients (65.5%) had a significant subclavian artery stenosis. We found a significant correlation between preoperative symptoms and subclavian artery stenosis (P=0.018) and overall perioperative stroke was seen more frequently in patients with subclavian artery stenosis (P=0.041). A significant positive correlation was observed between vertebral artery stenosis and subclavian artery stenosis (P=0.01). Conclusion: Patients who were diagnosed with both subclavian artery stenosis and IASBPD (≥ 20 mmHg) had a higher risk of postoperative stroke and death, had higher total cholesterol, LDL-C, blood creatinine level, and were more symptomatic.

Anatomoclinical features of trigeminal neuralgia caused by vertebrobasilar dolichoectasia

Vertebrobasilardolichoectasia (VBDE) is a rare cause of trigeminal neuralgia (TN). The size and tortuous course of the offending vessel poses a particular challenge when attempting a surgical treatment with microvascular decompression. There are few reports on the radiological and surgical anatomy encountered in this condition. The anatomical and radiological features of a surgical series of 7 patients with TN caused by VBDE and treated with microvascular decompression (MVD) are presented. Morphometric measurements and three-dimensional reconstructions obtained from preoperative magnetic resonance imaging were compared with microsurgical findings. Trigeminal nerve compression was found on the left side in six cases (86%). The neurovascular compression was caused by the basilar artery (BA) in 4 cases and the vertebral artery (VA) in three cases, with two cases showing a multiple compression involving other vessels. The BA showed a mean maximal diameter of 6,5 mm (5-9,1 mm), a mean lateral deviation of 19,3 mm (14,4- 22,1 mm) and a mean elevation of the basilar tip above the dorsum sellae of 10,5 mm (4,4-14,8 mm). MVD was successfully performed in all patients yielding a permanent pain relief in six of the patients. Preoperative assessment of the neurovascular relations within the cerebellopontine angle is paramount for the surgical planning in patients with TN caused by VBDE

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Manipulación cervical: aproximación anatómico-biomecánica frente a los posibles riesgos e implicaciones prácticas / Cervical manipulation: anatomical and biomechanical approach facing possible risks and practical implications

La manipulación articular es una técnica fisioterápica con cierto "estatus" dentro de nuestro arsenal terapéutico, fruto de la promesa de buenos resultados a muy corto plazo de tiempo, el halo de misticismo que la envuelve, el miedo desencadenado por reacciones adversas durante su aplicación y el tipo de impulso a desarrollar. Aunque la bibliografía especializada casi siempre evidencie un único tipo de manipulación, la rotatoria, la manipulación puede realizarse mediante movimientos translatorios de tracción o deslizamiento que ofrecen óptimos resultados en la ganancia de movimiento articular y minimizan el riesgo de sobreestresar las estructuras intraarticulares. Por lo tanto, un diagnóstico de hipomovilidad articular con una sensación terminal firme que indique la correcta aplicación de una manipulación translatoria evita desencadenar una reacción adversa a nuestro tratamiento. En la columna cervical, y en especial sobre la columna cervical superior, esta situación se magnifica, ya que las reacciones adversas pueden ser incluso fatales para el paciente. Conclusión. La eficacia y seguridad de la manipulación cervical depende de una apropiada indicación, un diagnóstico preciso, la elección adecuada del tipo de manipulación y su correcta aplicación

Joint manipulation is a physiotherapy technique with certain "status" inside our therapeutical tools due to the promise of good results in a very brief period of time, the halo of mysticism that surrounds it, the fear produced by side effects during its application and the type of impulse to be developed. Although literature almost always refers to only one kind of manipulation, the rotatoric one, manipulation can be made through translatoric movements of traction and gliding that offer optimal results in increasing joint movement and minimize the risk of excessive stress on the intraarticular structures. Therefore, a diagnosis of joint hypomobility with a firm end feel suitable for the indication of a correct application of translatoric manipulation avoids eliciting an adverse reaction to our treatment. In the cervical spine and specially in the upper cervical spine, this situation is magnified because adverse reactions in this region could be fatal for the patient. Conclusion. The effectiveness and security of cervical manipulation depends on an appropriate indication, a precise diagnosis, and adequate election of the type of manipulation and its correct application

Valor pronóstico de la cefalea en el infarto cerebral cardioembólico / Pronostic value of headache in cardioembolic stroke

Fundamento y objetivo: Analizar las variables predictoras de los infartos cerebrales de origen embólico cardíaco (ICE) que presentan cefalea. Pacientes y método: Estudio de 480 pacientes con ICE incluidos en el Registro de Ictus del Hospital Universitari del Sagrat Cor de Barcelona durante un período de 17 años. Se ha efectuado una comparación entre los pacientes con ICE con y sin cefalea. Se ha realizado un análisis multivariante para individualizar los factores clínicos y topográficos independientes relacionados con la presencia de cefalea en los ICE. Resultados: Presentaron cefalea 38 pacientes, lo que representa el 7,9% del total de ICE (n = 480). El deterioro neurológico precoz se presentó en 40 pacientes (8,3%) y fue más frecuente en presencia de cefalea que en ausencia de ésta (el 17,5 frente al 7%; p < 0,03). En el análisis multivariante el deterioro neurológico precoz constituyó un factor predictor independiente asociado a los ICE con cefalea (odds ratio [OR] = 3,34, y OR = 3,36). El resto de las variables clínicas asociadas con la presencia de cefalea en los ICE fueron: parálisis de nervios craneales (OR = 7,54; intervalo de confianza [IC] del 95%,1,98-28,70), ataxia (OR = 4,88; IC del 95%, 1,65-14,50), cardiopatía isquémica (OR = 3,02; IC del 95%, 1,41-6,45), hiperlipemia (OR = 2,61; IC del 95%, 1,08-6,28), edad (OR = 0,96; IC del 95%, 0,93-0,99) e inicio súbito (OR = 0,43; IC del 95%, 0,21-0,91). Las variables topográficas asociadas fueron la afectación de las arterias cerebelosa posteroinferior (OR = 21,41; IC del 95%, 3,10-148,04), basilar (OR = 9,04; IC del 95%, 1,87-43,66) y cerebral posterior (OR = 6,12; IC del 95%, 2,30-16,29). Conclusiones: La cefalea en los ICE se relaciona con los síntomas clínicos y la topografía asociada al territorio vertebrobasilar, y su presencia se asocia a un deterioro neurológico precoz, situación relacionada con un peor pronóstico de la enfermedad

Background and objective: To characterize the clinical features, prognosis and clinical predictors of headache in cardioembolic stroke (CS). Patients and method: Descriptive study of 480 patients with CS included in the Sagrat Cor Hospital of Barcelona Stroke Registry over a 17 year period. The vascular risk factors, clinical profiles and topographic data in CS with and without headache were compared. The independent predictive value of each variable on the development of headache in CS was assessed with a logistic regression analysis. Results: Headache was diagnosed in 38 of 480 patients (7.9%) with CS Early neurologic deterioration was present in 40 patients (8.3%), and was significantly more frequent in patients with than without headache (17.5% vs 7%; p<0.03). The presence of early neurologic deterioration was a significant predictive variable associated with headache in CS in the 2 logistic regression models (odds ratio [OR]=3.34, and OR=3.36). Other clinical variables were: cranial nerve palsy (OR=7.54; 95% confidence interval [CI], 1.98-28.70), ataxia (OR=4.88; 95% CI, 1.65-14.50), ischemic heart disease (OR=3.02; 95% CI, 1.41-6.45), hyperlipidemia (OR=2.61; 95% CI, 1.08-6.28), age (OR=0.96; 95% CI, 0.93-0.99), and sudden onset (OR=0.43; 95% CI, 0.21-0.91). Topographic profile were: posteroinferocerebellar artery involvement (OR=21.41; 95% CI, 3.10-148.04), basilar artery involvement (OR = 9.04; 95% CI, 1.87-43.66) and cerebral posterior involvement (OR=6.12; 95% CI, 2.30-16.29). Conclusions: Headache in CS is more frequent in vertebrobasilar involvement. Headache is related with early neurological deterioration and associated with increased morbidity and mortality

Dolicoectasia basilar e ictus de repetición: dos nuevos casos / Basilar dolichoectasia and repeated strokes: two new cases

Introducción. La dolicoectasia vertebrobasilar (DEB) se define como la elongación, dilatación y tortuosidad de las arterias de la circulación cerebral posterior. La prevalencia es baja, al igual que la incidencia de ictus secundarios. El tratamiento es controvertido. Las manifestaciones clínicas dependen del territorio vascular afectado, tamaño del aneurisma y compresión de las estructuras adyacentes. Se manifiesta habitualmente por cuadros isquémicos focales del territorio posterior. Los avances en las técnicas de neuroimagen y su extensión a hospitales de nivel básico han incrementado el diagnóstico de DEB. Caso clínico. Presentamos dos casos de DEB manifestada como ictus de repetición. Se optó por el tratamiento antiagregante como opción terapéutica por motivos clínicos y sociales. Conclusión. La DEB es una rara entidad que se manifiesta más frecuentemente como cuadros isquémicos en personas de edad avanzada. La antiagregación plaquetaria puede ser una opción válida en estos pacientes

Introducction. Dolichoectasia vertebrobasilar (DEB) is defined as dilatation and winding of posterior brain circulation. The prevalence is low, as the same as incidence of secondary strokes. The treatment is controversial. The clinical manifestation depend on the vascular territory involved, aneurysm size and compression of adjacent structures. Often it is presented as strokes of vertebrobasilar territory. Advance in neuroimaging technique and the access to primary hospital have increased the diagnostic of DEB. Clinical cases. We report two cases of DEB its present as repeated strokes. Platelet antiagregation was select in basis to social and clinical reason. Conclusion. DEB is a rare entity. Frequently it present as strokes in elderly patients. Platelet antiagregation can be a reasonable therapeutic option

Ictus pontino secundario a meningioma de foramen magno / Pontien stroke secondary to a foramen magnum meningioma

Introducción. El meningioma es uno de los tumores más frecuentes del sistema nervioso central, con una incidencia estimada entre el 15 y el 20% de todos los tumores cerebrales. Son generalmente benignos y de lento crecimiento. Su presentación como infarto cerebral es excepcional. Caso clínico. Paciente mujer, diestra, de 75 años, con antecedentes personales de hipertensión arterial, que acudió a urgencias por presentar disartria grave, de forma súbita, acompañada de pérdida de fuerza en las extremidades izquierdas, una parálisis facial supranuclear izquierda y síndrome de Horner derecho. La tomografía computarizada craneal puso de manifiesto un infarto lacunar en dicha localización, sin apreciarse otras lesiones. El estudio neurovascular incluyó un Doppler transcraneal, que no pudo insonar la arteria vertebral izquierda ni la arteria basilar. La resonancia magnética craneal mostró la existencia de un meningioma de foramen magno, con distorsión vascular vertebrobasilar. La paciente evolucionó de forma favorable y fue sometida a radiocirugía. Conclusión. Se trata de un caso único al describir un meningioma de fosa posterior que presenta como clínica inicial un ictus pontino por afectación vascular (AU)

Introduction. Meningioma is one of the most frequent tumours affecting the central nervous system, with an estimated incidence of between 15 and 20% of all brain tumours. They are generally benign and slow growing. Their appearing as a cerebral infarction is very rare. Case report. A right-handed 75-year-old female patient with a personal history of arterial hypertension, who visited the Emergency Department because of the sudden onset of severe dysarthria, accompanied by loss of strength in the left limbs, supranuclear facial palsy on the left side and Horner syndrome on the right. A computerised tomography scan of the brain revealed a lacunar infarct in said location, with no other appreciable damage. The neurovascular study included a transcranial Doppler, which was unable to insonate the left vertebral artery or the basilar artery. Magnetic resonance imaging of the head revealed a foramen magnum meningioma, with vertebrobasilar vascular distortion. The patient progressed favourably and was submitted to radiosurgery. Conclusions. The case reported here is unique, since it describes a meningioma of the posterior fossa that appears in the form of the initial symptoms of a pontine stroke due to a vascular disorder (AU)