Posterior circulation collaterals as predictors of outcome in basilar artery occlusion: a sub-analysis of the BASICS randomized trial.

Introduction and purpose: Basilar artery occlusion (BAO) is still one of the most devastating neurological conditions associated with high morbidity and mortality. In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare two grading systems (BATMAN score and PC-CS) in terms of prognostic value. Methods: We performed a sub-analysis of the BASICS trial. Baseline clinical and imaging variables were analyzed. For the imaging analysis, baseline CT and CTA were analyzed by a central core lab. Only those patients with good or moderate quality of baseline CTA and with confirmed BAO were included. Multivariable binary logistic regression analysis was used to test the independent association of clinical and imaging characteristics with a favorable outcome at 3 months (defined as a modified Rankin Score of ≤3). ROC curve analysis was used to assess and compare accuracy between the two collateral grading systems. Results: The mean age was 67.0 (±12.5) years, 196 (65.3%) patients were males and the median NIHSS was 21.5 (IQR 11-35). Median NCCT pc-ASPECTS was 10 (IQR10-10) and median collateral scores for BATMAN and PC-CS were 8 (IQR 7-9) and 7 (IQR 6-8) respectively. Collateral scores were associated with favorable outcome at 3 months for both BATMAN and PC-CS but only with a modest accuracy on ROC curve analysis (AUC 0.62, 95% CI [0.55-0.69] and 0.67, 95% CI [0.60-0.74] respectively). Age (OR 0.97, 95% CI [0.95-1.00]), NIHSS (OR 0.91, 95% CI [0.89-0.94]) and collateral score (PC-CS - OR 1.2495% CI [1.02-1.51]) were independently associated with clinical outcome. Conclusion: The two collateral grading systems presented modest prognostic accuracy. Only the PC-CS was independently associated with a favorable outcome at 3 months.

The Vertebrobasilar Trunk and Its Anatomical Variants: A Microsurgical Anatomical Study.

BACKGROUND: The trunk of the basilar artery has not been included in microanatomy studies. Anatomical variants of the perforant branches of the vertebrobasilar trunk and their relationship with neural structures are very important in surgical approaches. Surgical dissection for the treatment of vascular lesions requires a perfect knowledge of the microsurgical anatomy. METHODS: We conducted a descriptive analysis of 50 brains, which were fixed with formalin at 10% for 2 weeks, and the arterial system was injected with colored latex. After microsurgical dissection, it was divided into three segments: the lower portion went from the anterior spinal artery to the anteroinferior cerebellar artery, the middle segment was raised from the upper limit of the lower portion to the origin of the superior cerebellar artery, and the upper segment ranged from the previous portion until the origin of the posterior cerebral artery. RESULTS: The basilar artery had an average length of 30 mm. The average diameter at its junction with the vertebral arteries was 4.05 mm. The average middle segment was 3.4 mm in diameter and 15.2 mm in length. The diameter of the upper segment was 4.2 mm, and its average length was 3.6 mm. The average number of bulbar arteries was three, and their average diameter was 0. 66 mm. The number of caudal perforator arteries were five on average, with a diameter of 0.32 mm. We found three rare cases of anatomical variants in the vertebra-basilar junction. CONCLUSIONS: The basilar artery emits penetrating branches in its lower, middle, and upper portions. The origin of penetrating branches was single or divided after forming a trunk. However, we observed long branches from perforant arteries.

Microsurgery for brain aneurysms in an accessory A2 and basilar arteries: a rare case presentation and surgical video.

We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5 quadriparesis and a Glasgow coma scale (GCS) score of 8, which merited neurocritical intensive care. Brain imaging suggested the presence of two lesions: (i) a fusiform aneurysm of 12 × 7 mm in an accessory A2 artery of the anterior cerebral artery and (ii) an unruptured saccular aneurysm of 3.3 × 2.8 mm in the distal segment of the basilar artery. He was deemed a candidate for microsurgical management. Postoperatively, he had 4/5 quadriparesis, paresis of the right oculomotor nerve, and a GCS score of 13. A 3-month follow-up showed a significant improvement in neurological function with a score of 2 on the modified Rankin scale. The presented case illustrates the relevance of a nuanced acquaintance to operate in diseased anatomical variants and complex pathologies of narrow corridors.

Cerebrovascular Complications Associated With Iatrogenic Fungal Meningitis Following Surgical Procedures in Mexico.

BACKGROUND: The current fungal meningitis outbreak caused by contaminated epidural anesthesia with Fusarium solani among patients who underwent surgical procedures in Matamoros, Mexico remains a cause of concern. Its association with an increased susceptibility for cerebrovascular complications (CVC) has not been reported. This single-center study describes 3 patients with a unique pattern of CVC attributed to fungal meningitis. METHODS: A retrospective case series of patients diagnosed with fungal meningitis following surgical procedures under contaminated epidural anesthesia who developed a unique pattern of CVC during their hospitalization. RESULTS: Three female patients (mean age, 35 years) with CVC due to iatrogenic fungal meningitis were included. Positive Fungitell ß-D-glucan assay in cerebrospinal fluid was documented in all cases, and F. solani was confirmed by polymerase chain reaction in case 3. All cases were complicated by severe vertebrobasilar circulation vasculopathy and arterial dissections with resultant subarachnoid hemorrhage and intraventricular hemorrhage, ultimately leading to patients' death. CONCLUSIONS: The death toll from the ongoing fungal meningitis outbreak keeps rising, underscoring the need for early recognition and aggressive treatment. We highlight the risk for vertebrobasilar circulation CVC among these patients. The angioinvasive nature of F. solani is yet to be clarified; however, a clear pattern has been observed. Public health awareness should be raised and a strong response should be pursued.

Syringomyelia: Retrospective Analysis of 30 Surgically Treated Patients from the Northeast of Brazil / Siringomielia: Análise retrospectiva de 30 casos operados no nordeste brasileiro

Introduction Syringomyelia is a chronic disease characterized by the presence of intramedullary cavity. Chiari malformation (CM) and basilar impression (BI) are conditions usually associated with syringomyelia. Its prevalence has wide geographical variation, being higher in the Northeast of Brazil, making it relevant to study the subject in this region. Objective To analyze the frequency of signs, symptoms, and surgical aspects observed in patients undergoing decompressive treatment. Methods We performed a retrospective analysis of the medical records of patients diagnosed with syringomyelia who received decompressive surgical treatment in various hospitals in João Pessoa, Paraíba, between 1994 and 2021. Results Thirty patients were analyzed. Twenty-nine (96.7%) presented CM and 27 (90.0%) also presented BI. A wide variety of symptoms was found, with significant prevalence of muscle weakness, neck pain, and headache. Brevicollis, a finding considered typical of the Northeastern region and associated with craniocervical junction malformations, was present in 66.7%. The surgical technique used in 90% of patients was similar. Fourteen (46.7%) patients presented difficult craniocervical junction and 4 (13.3%) had occipital bone assimilation. Eighteen (60.0%) presented thickening of the arachnoid membrane. Postoperatively, there was clinical improvement in 21 patients (70%). Conclusions The sample majorly had CM and BI associated with syringomyelia. High prevalence of signs and symptoms related to the Brazilian northeastern phenotype was also found. Syringomyelia, therefore, has peculiarities in the population of the Northeast of Brazil that, when described, allow better understanding of the pathology in this group.

Introdução Siringomielia é uma enfermidade crônica caracterizada pela presença de cavidade intramedular. Costuma vir associada a condições como malformação de Chiari (MC) e impressão basilar (IB). Sua prevalência tem grande variação geográfica, sendo maior no nordeste brasileiro, o que torna relevantes estudos sobre o tema nessa região. Objetivo Analisar a frequência de sinais, sintomas e aspectos cirúrgicos observados em pacientes submetidos a tratamento descompressivo. Método Foi realizada análise retrospectiva das informações contidas nos prontuários de pacientes diagnosticados com siringomielia submetidos a tratamento cirúrgico descompressivo em vários hospitais de João Pessoa, Paraíba, entre 1994 e 2021. Resultados Foram analisados 30 pacientes, dos quais 29 (96,7%) apresentaram MC associada e 27 (90,0%) também tinham IB. Houve grande variedade de sintomas, com importante prevalência de fraqueza muscular, cervicalgia e cefaleia. Brevicolia, um achado considerado típico do nordestino e associado a malformações da junção craniocervical, esteve presente em 66,7% dos pacientes. A técnica cirúrgica utilizada em 90% dos pacientes foi semelhante. Quatorze (46,7%) pacientes apresentaram junção crânio-cervical difícil; e quatro (13,3%) apresentaram assimilação do osso occipital. Dezoito (60,0%) apresentaram espessamento da membrana aracnoide. No pós-operatório, houve melhora clínica em 21 pacientes (70%). Conclusão A expressiva maioria da amostra possuía MC e IB associadas à siringomielia. Nota-se também grande prevalência de sinais e sintomas relacionados ao fenótipo nordestino. A siringomielia, portanto, possui peculiaridades na população do Nordeste brasileiro que, ao serem descritas, permitem a melhor compreensão da patologia nesse perfil de pacientes.

Endovascular Treatment of Basilar Artery Stenosis / Tratamento endovascular de estenose de artéria basilar

Objective To analyze epidemiological characteristics and therapeutic evolution of patients with basilar artery (BA) stenosis who underwent endovascular therapy in a reference service. Methods Observational retrospective study of a case report of individuals with BA stenosis who underwent endovascular therapy in an endovascular neurosurgery reference service, between November 2005 and May 2018. Results The prevalence was higher among male patients, with 60% of the cases. As for age, it ranged from 18 to 81 years old, with a mean of 60.2 years old. In terms of comorbidities, systemic arterial hypertension was found in 93% of the patients, and dyslipidemia in 86.7%. The initial symptoms were previous history of ischemic cerebrovascular accident (CVA) in 43.3% of the cases and dizziness in 46.7%. The degree of stenosis ranged from 90 to a 98% of obstruction, with a mean of 92.8%. Neurological deficit was observed in 23.3% of the cases postoperatively, and the postoperative death rate was 10% (3/30). There were no intraoperative adverse events. Conclusion The applicability of endovascular stenting therapy in high-grade BA stenosis proved to be a safe and effective technique with lower morbimortality rates and faster recovery.

Objetivo Analisar as características epidemiológicas e a evolução terapêutica de pacientes com estenose de artéria basilar (AB) submetidos a terapia endovascular em serviço de referência. Metodologia Estudo retrospectivo observacional de trinta pacientes com estenose de AB submetidos à terapia endovascular em serviço de referência em neurocirurgia endovascular de Blumenau, SC, Brasil, no período de novembro de 2005 a maio de 2018. Resultados O sexo masculino foi o mais prevalente, com 60% dos casos. A idade variou de 18 a 81 anos, sendo a média de 60,2 anos. Quanto à presença de comorbidades, observou-se que a hipertensão arterial sistêmica esteve presente em 93% dos casos e a dislipidemia em 86,7% dos casos. As sintomatologias iniciais observadas foram história prévia de AVE isquêmico em 43,3% dos casos e tontura em 46,7%. O grau de estenose variou de 90 a 98% de obstrução, com a média de 92,8%. Os stents de balão expansíveis foram os mais utilizados, sendo o da marca Pro-Kinect Energy o mais utilizado (60%). Por fim, em 23,3% dos casos, observou-se déficit neurológico no pós-operatório, e a taxa de óbito foi de 10% (3/30) no pós-operatório. Não ocorreu nenhum evento adverso intraoperatório. Conclusão A aplicabilidade da terapia endovascular com utilização de stent em quadros de alto grau de estenose de AB mostrou-se técnica segura e eficaz com menores taxas de morbimortalidade e recuperação mais rápida.

The role of sphenoid bone in basilar invagination pathophysiology.

Basilar invagination (BI) is characterized by rostral dislocation of the cervical spine toward the skull base. The craniometrics of the skull base have shown significant differences among craniocervical junction malformations. The sphenoid bone is the center of the skull base; however, no study has evaluated this bone in cases of BI. This was a cross-sectional study of MRI databanks from two institutions of the author's practice between 1985 and 2020. The craniometrics of the sphenoid bone were measured in BI patients and controls. Fifty-eight MRIs were selected, including 28 BI patients and 30 controls. The mean sphenoid crest-clivus length was 32.66 ± 4.7 mm in the BI group and 29.98 ± 3.0 mm in the control group (p = 0.01). The mean sphenoid planum-top of Dorsum sellae length was 28.53 ± 3.7 mm in the BI group and 26.45 ± 3.2 mm in the control group (p = 0.02). The mean tuberculum sellae-sphenoid floor height was 18.52 ± 4.4 mm in the BI group and 21.32 ± 2.9 mm in the control group (p = 0.00). The mean sella turcica-sphenoid floor height was 10.35 ± 3.8 mm in the BI group and 12.24 ± 3.5 mm in the control group (p = 0.05). The mean clivus length was 29.81 ± 6.3 mm in the BI group and 40.86 ± 4.2 mm in the control group (p = 0.00). The mean sphenoid length was 58.34 ± 7.4 mm in the BI group and 67.31 ± 6.0 mm in the control group (p = 0.00). The mean sphenoid angle was 116.33 ± 8.7° in the BI group and 112.36 ± 6.9° in the control group (p = 0.05). The BI sphenoid bone has shorter vertical dimensions and longer horizontal measures. This morphology promotes a flattening of the sphenoid angle. The sphenoid bone is significantly altered in BI, favoring the congenital hypothesis in the pathophysiology of this disease.

Anatomical Implications of Chiari I and Basilar Invagination (Type B) in the IV Ventricle and Cisterna Magna.

OBJECTIVE: To analyze the anatomical changes of the IV ventricle and cisterna magna in the Chiari malformation I (CMI) and basilar invagination (type B). METHODS: This is a controlled study with 161 exams of magnetic resonance imaging (MRI) of adults grouped into control (n = 37), basilar invagination (BI; n = 31), Chiari malformation I (CMI; n = 37), and CMI+BI (n = 56). The MRIs were analyzed using the visualization software Osirix (Pixmeo, Bernex, Geneva, version 3.8.2). The morphometric variables were: distance from the obex to the McRae line; length of the IV ventricle floor; and the area and volume of the cisterna magna. The univariate ANOVA followed by Tukey's post-hoc test was applied to evaluate the difference between the groups. The difference between sexes was evaluated by the t test for each group. RESULTS: Alterations in the cisterna magna and IV ventricle were more evident only in the CMI and CMI+BI groups. For both sexes, the CMI and CMI+BI groups showed: a reduction in the CSF space (P < 0.001), cisterna magna with volume reduction (P < 0.001), low position of the obex (P < 0.001), and IV ventricle more elongated (male P = 0.007 and female P < 0.001). The BI group had no significant change in the analysis by sex. CONCLUSIONS: The CMI (isolated and associated with BI) showed a low obex position and elongation of the IV ventricle due to traction towards the spinal canal. The reduction of cisterna magna volume added to the occupation of the cerebellar tonsils can impact in the cerebrospinal fluid dynamics. The BI when isolated was not related to alterations in the parameters of cerebrospinal fluid spaces studied.

[Basilar dolichoectasia and fusiform vertebral artery aneurysm: ischemic stroke of dual cause] / Dolicoectasia basilar y aneurisma fusiforme de arteria vertebral: accidente cerebrovascular isquémico de causa dual.

A 76-year-old woman arrived at the emergency department due to an ischemic stroke that affected the territory of the left anterior choroidal and basilar arteries. Imaging studies showed dolichoectasia basilar associated with a fusiform aneurysm with thrombi inside it in the left vertebral artery. Both anatomic abnormalities are associated with ischemic stroke.

Mujer de 76 años que acudió al servicio de urgencias por un accidente cerebro vascular isquémico que afectó el territorio de arteria coroidea anterior izquierda y basilar. Los estudios de imagen mostraron dolicoectasia basilar asociada a un aneurisma fusiforme con trombos en su interior en la arteria vertebral izquierda. Las dos anomalías anatómicas están asociadas a accidente cerebrovascular isquémico.

Foville syndrome: a neurological emergency of clinical relevance. case report

Introduction: Foville syndrome (inferior medial pontine syndrome) is a clinical entity that makes part of a subclassification of a broader category of posterior circulation stroke. It is characterized by a blockage of the basilar artery caused by lesions in the pontine tegmentum. This syndrome has a very low incidence worldwide, but its clinical relevance is considerable. Case report: A 41-year-old patient without any medical history was admitted to the emergency department due to signs of focal neurologic deficits. Imaging findings were compatible with an ischemic lesion in the brainstem, and cerebral angiography showed involvement of the basilar artery territory. The patient was diagnosed and followed up in the intensive care unit (ICU) until his recovery. Conclusion: Foville syndrome is a rare disease with high morbidity and mortality. Early recognition and a multidisciplinary approach are decisive to improve the patient's prognosis.

Introducción. El síndrome de Foville (síndrome pontino medial inferior) es una entidad clínica que hace parte de una subclasificación de la categoría más amplia de eventos cerebrovasculares de la circulación posterior, se presenta como resultado de la oclusión de la arteria basilar debido a lesiones en el tegmento pontino. Este síndrome tiene una muy baja incidencia a nivel mundial, pero es de gran relevancia clínica. Presentación del caso. Hombre de 41 años sin antecedentes patológicos, que ingresó al servicio de urgencias por signos de focalización neurológica. Sus hallazgos imagenológicos fueron compatibles con una lesión isquémica en el tronco encefálico y la angiografía cerebral evidenció un compromiso en el territorio de la arteria basilar. El paciente fue diagnosticado y se le dio seguimiento en la unidad de cuidados intensivos (UCI) hasta su rehabilitación. Conclusión. El síndrome de Foville es una enfermedad infrecuente y de alta mortalidad. El reconocimiento temprano de esta afección y un abordaje multidisciplinario son determinantes para mejorar el pronóstico del paciente.

Fossa navicularis magna: detección por tomografía computarizada de haz cónico / Fossa navicularis magna: detection by cone-beam computed tomography

Introducción: La identificación, interpretación y manejo de hallazgos incidentales en imagenología dental es imprescindible. Algunos de ellos requieren técnicas de imagen adicionales y remisión a profesionales de experiencia, otros únicamente su descripción. Una de estas variantes anatómicas se halla en el clivus, la fossa navicularis magna, asociada en pocos casos a repercusiones sistémicas. Objetivo: Describir las características de la fossa navicularis magna para su identificación mediante tomografía computarizada de haz cónico. Presentación de los casos: Tres pacientes de sexo femenino, con un rango de edad entre 35-71 años que acuden al Centro Odontológico de la Universidad San Martín de Porres para tratamientos de ortodoncia y rehabilitación oral. En estas áreas, como parte del protocolo se solicita tomografía computarizada de haz cónico por pieza retenida y elaboración de guías quirúrgicas respectivamente. El escaneo permite la identificación de un defecto tipo muesca en el clivus, de límites bien definidos y bordes corticalizados, lo que sugiere fossa navicularis magna. La historia clínica de los pacientes no sugirió implicaciones clínicas. Principales comentarios: Se informa y discute esta variante anatómica cuya presencia no requiere tratamiento y generalmente no tiene repercusiones sistémicas. En contados casos ha estado asociado con cuadros clínicos que amenazan la vida del paciente, precisamente porque puede servir como un trayecto para infecciones intracraneales. De ahí la necesidad de conocer y describir esta variante anatómica(AU)

Introduction: The identification, interpretation and management of incidental findings in dental imaging is essential. Some of them require additional imaging techniques and referral to experienced professionals, others only their description. One of these anatomical variants is found in the clivus, fossa navicularis magna, associated in few cases with systemic repercussions. Objective: Describe the characteristics of fossa navicularismagna for its identification by cone-beam computed tomography. Presentation of cases: Three female patients, with an age range between 35-71 years who come to the Dental Center of San Martín de Porres University for orthodontic treatments and oral rehabilitation. In these areas, as part of the protocol, cone-beam computed tomography per retained piece and development of surgical guides are requested, respectively. The scan allows the identification of a notch-like defect in the clivus, of well-defined boundaries and corticalized edges, suggesting fossa navicularis magna. The patients' medical history did not suggest clinical implications. Main comments: This anatomical variant is reported and discussed and its presence does not require treatment and generally has no systemic repercussions. In rare cases it has been associated with clinical pictures that threaten the patient's life, precisely because it can serve as a path for intracranial infections. Hence the need to know and describe this anatomical variant(AU)

Basilar artery tortuosity as a predictive factor for the efficacy of heparin adjuvant therapy in unilateral idiopathic sudden sensorineural hearing loss / Tortuosidade da artéria basilar como fator preditivo da eficácia da terapia adjuvante com heparina na perda auditiva neurossensorial súbita idiopática unilateral

Abstract Introduction Cochlear ischemia is hypothesized as one of the major etiologies of idiopathic sudden sensorineural hearing loss. Therefore, anticoagulant therapies are designed to be beneficial in certain patients with this condition. Objective This study aimed to determine which patients with idiopathic sudden sensorineural hearing loss would benefit from heparin treatment as adjuvant therapy. Methods In total, 134 patients who underwent magnetic resonance imaging for unilateral idiopathic sudden sensorineural hearing loss at a tertiary referral hospital between January 2014 and December 2018 were included in this retrospective study. All patients received Intratympanic steroid injections or heparin therapy plus oral corticosteroids. Radiological parameters of the vertebrobasilar system and clinical data from pre- and post-treatment assessments were analyzed. Results Most patients (71.6%) had a tortuous basilar artery The 65 patients with severe-to-profound idiopathic sudden sensorineural hearing loss showed a significant relationship between idiopathic sudden sensorineural hearing loss laterality and basilar artery displacement to the opposite side (p= 0.036), while the 69 patients with mild-to-moderate idiopathic sudden sensorineural hearing loss did not (p= 0.950). Additionally, the degree of basilar artery tortuosity was significantly associated with the degree of hearing impairment in the severe-to-profound idiopathic sudden sensorineural hearing loss group (p= 0.015). When idiopathic sudden sensorineural hearing loss occurred on the opposite side to basilar artery displacement, the improvement of hearing was significantly greater in patients treated with heparin than in those treated with intratympanic steroids (p= 0.041). Conclusion In a subset of patients with severe-to-profound idiopathic sudden sensorineural hearing loss, basilar artery tortuosity had a significant directional relationship with idiopathic sudden sensorineural hearing loss laterality. In these selected patients, a significant effect of heparin therapy on improving hearing was observed.

Resumo Introdução A isquemia coclear é considerada uma das principais etiologias da perda auditiva neurossensorial súbita idiopática. Portanto, espera-se que as terapias anticoagulantes sejam benéficas em certos pacientes com esse diagnóstico. Objetivo Determinar quais pacientes com perda auditiva neurossensorial súbita idiopática se beneficiariam do tratamento com heparina como terapia adjuvante. Método Foram incluídos neste estudo retrospectivo 134 pacientes submetidos à ressonância magnética por perda auditiva neurossensorial súbita idiopática unilateral em um hospital de referência terciário entre janeiro de 2014 e dezembro de 2018. Todos os pacientes receberam injeções intratimpânicas de corticosteroides ou terapia com heparina juntamente com corticosteroides orais. Os parâmetros radiológicos do sistema vertebro-basilar e os dados clínicos das avaliações pré e pós-tratamento foram analisados. Resultados A maioria dos pacientes (71,6%) apresentava uma artéria basilar tortuosa. Os 65 pacientes com perda auditiva neurossensorial súbita idiopática grave a profunda mostraram uma relação significativa entre a lateralidade da perda auditiva e o deslocamento da artéria basilar para o lado oposto (p = 0,036), enquanto os 69 pacientes com perda auditiva neurossensorial súbita idiopática leve a moderada não apresentaram esse deslocamento (p = 0,950). Além disso, o grau de tortuosidade da artéria basilar foi significativamente associado ao grau de deficiência auditiva no grupo com perda auditiva neurossensorial súbita idiopática grave a profunda (p = 0,015). Quando a perda auditiva neurossensorial súbita idiopática ocorreu no lado oposto ao deslocamento da artéria basilar, a melhoria da audição foi significativamente maior nos pacientes tratados com heparina do que naqueles tratados com injeções intratimpânicas de corticosteroide (p = 0,041). Conclusão Em um subgrupo de pacientes com perda auditiva neurossensorial súbita idiopática grave a profunda, a tortuosidade da artéria basilar mostrou uma relação direcional significativa com a lateralidade da perda auditiva. Nesses pacientes selecionados, foi observado um efeito significante da terapia com heparina na melhoria da audição.

Outcomes of acute basilar artery occlusion-real-world experience in a middle-income country.

OBJECTIVES: Our goal was to describe outcomes in a single-center, real-world series of patients with acute basilar artery occlusion in a middle-income country. In addition, we assessed potential outcome predictors. MATERIAL AND METHODS: Data from 28 patients were retrospectively reviewed. The primary outcome was death until last follow-up. Other outcomes were rates of favorable outcome until last follow-up and rates of intracranial hemorrhage. Outcomes were compared in subgroups according to several variables, including reperfusion (REP group) or no reperfusion (NOREP group) interventions, with chi-squared, Fisher's exact test, or Mann-Whitney tests. RESULTS: The rate of overall intrahospital death was 46%. Death until last follow-up occurred in 8/17 (47%) in the REP and in 7/11 (63%) of the NOREP group. Favorable outcomes were observed in 35.7% of the patients: 8/17 (47%) in REP and in 2/11 (18.1%) in NOREP. NIH stroke scale scores were significantly lower in patients with favorable outcomes. Intracranial hemorrhage was observed in 6/28 (21.4%) of the patients (all in REP group). Twenty patients were treated with anticoagulants within the first 24 h. No hemorrhage was observed in those treated with enoxaparin, while three occurred in subjects treated with unfractionated heparin. CONCLUSION: Together with other series, our results underscore the relevance of NIH stroke scale at admission as a prognostic marker, the importance of reperfusion to improve outcomes, and the need of clinical trials to compare the impact of treatment with anticoagulants within first 24 h in basilar artery occlusion.

Position-dependent arm dyskinesia due to severe craniocervical malformation.

CONTEXT: Spinal-generated movement disorders are a complex group of medical conditions, frequently misdiagnosed, originating in the spinal cord or from combined peripheral and central nervous system involvement. In this case report, we describe a novel form of position-dependent dyskinesia due to severe craniocervical malformation. FINDINGS: An 83-year-old woman with basilar invagination at the C2 vertebra above the line of Chamberlain, occipitocervical lordosis, platybasia with a short clivus, ankylosis of the C1-C2 complex and fusion of the C1 arch developed an unusual pattern of position-dependent left arm dyskinesia triggered by bending her neck forward with simultaneous contact of the flexed elbow with a flat surface. Symptoms did not improve with anticonvulsants and she progressed and died suddenly. CONCLUSION/CLINICAL RELEVANCE: A newly described form of position-dependent arm dyskinesia can be associated with severe craniocervical malformation.

Morphologic characterisation of the posterior inferior cerebellar artery. A direct anatomic study.

BACKGROUND: The number of studies on the cerebellar arteries has increased. The purpose of this study was to determine the morphological expression of posterior inferior cerebellar artery in a sample of Colombian population. MATERIALS AND METHODS: One hundred eighty-six posterior inferior cerebellar arteries of fresh cadavers were studied. In each specimen, vertebral arteries were injected with 100 mL of semi-synthetic resin, dyed with mineral red. RESULTS: In the 93 blocks of brainstem and cerebellum evaluated, 174 (93.5%) posterior inferior cerebellar arteries were found. Also, there were 12 (6.5%) ageneses. There was single posterior inferior cerebellar artery in 159 (91.4%) samples and duplicate in 10 (5.7%), while 5 (2.9%) specimens showed hypoplasia. The posterior inferior cerebellar artery originated from the vertebral artery in 121 (69.5%) samples and from the basilar artery in 42 (24.1%) samples; while in 11 (6.4%) it originated in a common trunk with the anterior inferior cerebellar artery. In 101 (83.5%) cases, the posterior inferior cerebellar artery originated from the intracranial segment of the vertebral artery, while 20 (16.5%) samples originated from the extracranial segment. The calibres of posterior inferior cerebellar artery in its proximal and distal segments were 1.45 ± 0.37 mm and 1.33 ± 0.31 mm, respectively. CONCLUSIONS: This study, carried out in cadaveric material, provides relevant qualitative and morphometric information of the posterior inferior cerebellar artery, useful for the diagnosis and clinical management, as well as for the surgical approaches that may compromise this structure.

Basilar artery tortuosity as a predictive factor for the efficacy of heparin adjuvant therapy in unilateral idiopathic sudden sensorineural hearing loss.

INTRODUCTION: Cochlear ischemia is hypothesized as one of the major etiologies of idiopathic sudden sensorineural hearing loss. Therefore, anticoagulant therapies are designed to be beneficial in certain patients with this condition. OBJECTIVE: This study aimed to determine which patients with idiopathic sudden sensorineural hearing loss would benefit from heparin treatment as adjuvant therapy. METHODS: In total, 134 patients who underwent magnetic resonance imaging for unilateral idiopathic sudden sensorineural hearing loss at a tertiary referral hospital between January 2014 and December 2018 were included in this retrospective study. All patients received Intratympanic steroid injections or heparin therapy plus oral corticosteroids. Radiological parameters of the vertebrobasilar system and clinical data from pre- and post-treatment assessments were analyzed. RESULTS: Most patients (71.6%) had a tortuous basilar artery The 65 patients with severe-to-profound idiopathic sudden sensorineural hearing loss showed a significant relationship between idiopathic sudden sensorineural hearing loss laterality and basilar artery displacement to the opposite side (p = 0.036), while the 69 patients with mild-to-moderate idiopathic sudden sensorineural hearing loss did not (p = 0.950). Additionally, the degree of basilar artery tortuosity was significantly associated with the degree of hearing impairment in the severe-to-profound idiopathic sudden sensorineural hearing loss group (p = 0.015). When idiopathic sudden sensorineural hearing loss occurred on the opposite side to basilar artery displacement, the improvement of hearing was significantly greater in patients treated with heparin than in those treated with intratympanic steroids (p =  0.041). CONCLUSION: In a subset of patients with severe-to-profound idiopathic sudden sensorineural hearing loss, basilar artery tortuosity had a significant directional relationship with idiopathic sudden sensorineural hearing loss laterality. In these selected patients, a significant effect of heparin therapy on improving hearing was observed.

Endovascular management of dissecting posterior cerebral artery aneurysm associated with persistent hypoglossal artery: A case report.

Persistent embryological connections between the anterior and posterior circulations are rare entities. Persistent hypoglossal artery is the second most common persistent carotid-basilar anastomosis. As it is often associated with hypoplasia of vertebral arteries, it poses a challenge during endovascular interventions. We present a case of a 32-year-old woman who presented with occipital headache of four weeks' duration. Magnetic Resonance Angiography showed hypoplastic vertebral arteries with a persistent hypoglossal artery arising from the cervical segment of the left internal carotid artery and supplying the entire posterior circulation, associated with a dissecting aneurysm of the right posterior cerebral artery. Endovascular parent vessel occlusion was performed for the dissecting posterior cerebral artery aneurysm by navigating the guide catheter, microwire, and microcatheter through the persistent hypoglossal artery because the vertebral arteries were hypoplastic. Post-intervention, the patient did not develop any neurological deficit and was discharged in a stable condition.

Conexões embriológicas persistentes entre as circulações anterior e posterior são entidades raras. A artéria hipoglossa persistente é a segunda anastomose carotídeo-basilar persistente mais comum. Como está frequentemente associada à hipoplasia das artérias vertebrais, apresenta um desafio durante as intervenções endovasculares. Apresentamos o caso de uma mulher de 32 anos que apresentou cefaleia occipital com duração de quatro semanas. A angiografia por ressonância magnética mostrou artérias vertebrais hipoplásicas com artéria hipoglossa persistente surgindo do segmento cervical da artéria carótida interna esquerda e suprindo toda a circulação posterior com um aneurisma dissecante da artéria cerebral posterior direita. A oclusão endovascular do vaso parental foi realizada para o aneurisma da dissecção da artéria cerebral posterior pela passagem de cateter guia, microfio e microcateter pela artéria hipoglossa persistente, pois as artérias vertebrais eram hipoplásicas. Após a intervenção, a paciente não apresentou déficit neurológico e recebeu alta em uma condição estável.

Acute basilar artery occlusion (BAO): a pictorial review of multimodal imaging findings.

Acute basilar artery occlusion (BAO) is an uncommon cause of stroke; however, it constitutes a serious medical emergency and is associated with elevated mortality rates as well as unfavorable functional outcomes. This is especially true when it is not rapidly diagnosed, and the initiation of reperfusion therapies is delayed. Its etiology is mainly embolic or atherosclerotic, and it often presents with non-specific signs and symptoms (e.g., vertigo, cephalalgia, reduced consciousness, or hemiparesis) that can simulate an anterior circulation stroke. Therefore, obtaining imaging studies that include computed tomography (CT), computed tomography angiography (CTA), and diffusion-weighted magnetic resonance imaging (DWI MRI) as part of the diagnostic approach is crucial to make an accurate diagnosis. The main pillar of acute BAO treatment is early recanalization using intravenous thrombolysis, mechanical thrombectomy, or bridging therapy, in which both methods are used. This pictorial essay illustrates the essential role that multimodal imaging plays in the prompt diagnosis, management, and overall outcome of patients with acute BAO.

Thrombectomy for Posterior Circulation Stroke: Predictors of Outcomes in a Brazilian Registry.

BACKGROUND: Acute basilar artery occlusion is a devastating life-threatening condition. Early recanalization is the therapeutic goal in patients with acute ischemic stroke. Despite the high rates of recanalization achieved with modern devices for basilar occlusions, many patients have had poor clinical outcomes. This study aimed to assess the predictors of good and poor outcomes among patients with basilar artery occlusion treated with thrombectomy. METHODS: A consecutive registry of 80 patients was included in this retrospective study. The primary end point was to access variables associated with neurologic outcomes defined by a modified Rankin Scale (mRS) score of 0-2, symptomatic intracranial hemorrhage (sICH), and mortality at 3 months follow-up. RESULTS: Recanalization was achieved in 86.2%, and the sICH rate was 8.7%. A good neurologic outcome (mRS score 0-2) was observed in 26.2% and a moderate outcome (mRS score 0-3) in 32.5% of patients. The mortality was 38.7% at 3 months follow-up. CONCLUSIONS: After thrombectomy for posterior circulation strokes, young patients, V4-proximal basilar occlusion, (high) baseline posterior circulation Alberta Stroke Program Early CT Score, and complete recanalization were independent predictors of good neurologic outcomes. Failure to recanalize was strongly related to sICH and mortality. In addition, diabetes, atrial fibrillation, and baseline National Institutes of Health Stroke Scale scores ≥10 had an independent association with mortality. This study contributes to the knowledge required to optimize recanalization treatments for posterior circulation strokes and may help to improve future clinical studies.