Cognitive and Functional Impairment in Stroke Survivors with Basilar Artery Occlusive Disease.

BACKGROUND: Despite growing literature on posterior vascular disease, specific information about the cognitive and functional profiles of patients with basilar artery occlusion disease (BAOD) is scarce. The aims of this study were (1) to compare the cognitive statuses of BAOD survivors versus healthy controls and (2) to correlate the functional capacity outcomes with the cognitive profiles of BAOD patients. METHODS: Comprehensive cognitive and functional assessments were carried out in 28 patients with BAOD and 27 age- and education level-matched healthy controls. RESULTS: Compared to matched controls, patients presented impairments in selective, sustained, and set-shifting attention, processing speed, visuospatial skills, mental flexibility, and monitoring rules. There were significant deficits in verbal episodic memory (immediate and delayed recall) and visuospatial episodic memory (immediate and delayed recall and recognition). Functional capacity outcomes were significantly related to the cognitive test results. Seventy-five percent of patients had a Modified Rankin Scale score of 0 or 1. CONCLUSIONS: Our results indicate good functional outcomes in a selected group of BAOD survivors, despite the presence of subnormal performance on some cognitive tests, including tests of attention, executive function, and long-term memory.

Cognitive problems related to vertebrobasilar circulation.

Neurodegenerative disorders are characterized by decreased regional cerebral blood flow. Supporting this concept, both cognitive training exercises and physical activity promote blood flow increase and correlate with healthy cognitive aging. The terminal branches of the posterior circulation supply blood to areas of the brain, such as the thalamus, hippocampus, occipital lobe, and cerebellum, involved with important intellectual functions, particularly recent memory, visual-spatial functioning, and visuomotor adaptations. Amnesia and visual agnosia may be a complication of not only posterior circulation infarctions but also vertebrobasilar insufficiency (VBI) without accompanying structural infarcts. The cognitive impairment maybe a manifestation of transient attacks and may persist beyond resolution of symptoms related to ischemia. Early recognition of cognitive deficits in the VBI patient is important because several recent reports show stent placements or medical treatment may improve cognition.

Multimodal recanalization therapy in acute basilar artery occlusion: long-term functional outcome and quality of life.

BACKGROUND AND PURPOSE: Multimodal recanalization therapy in patients with acute basilar artery occlusion provides high recanalization rates. A substantial subset of treated patients survives with only minor or moderate functional handicap. However, long-term functional outcome and quality of life in these patients have rarely been systematically analyzed. METHODS: In this monocentric retrospective study, we analyzed mortality, long-term functional outcome (modified Rankin Scale), and quality of life (36-Item Short-Form Health Survey questionnaire) in all consecutive patients who had been treated for acute basilar artery occlusion in our institution between December 2002 and December 2009. RESULTS: Ninety-one patients (57 male; median age, 65 years; range, 20-89 years) were treated by multimodal recanalization therapy. This included intravenous thrombolysis (n=32) with consecutive on-demand intra-arterial therapy (n=23) or intra-arterial therapy alone (n=59). The overall recanalization rate was 89%. After a median observation time of 4.2 years (range, 0.5-7.4 years), the mortality rate was 59%. Among the 35 survivors, 26 patients (74%) had a good or moderate long-term functional outcome (modified Rankin Scale ≤3). Health-related quality of life was better than that of unselected patients with stroke. Backward stepwise logistic regression identified intravenous thrombolysis (P=0.002) and female sex (P=0.001) as predictors of favorable functional long-term outcome (modified Rankin Scale ≤3). Coma at admission (Glasgow Coma Scale ≤8) was associated with poor outcome (modified Rankin Scale ≥4; P=0.036). CONCLUSIONS: Long-term survival is achieved in approximately 40% of patients with basilar artery occlusion treated with multimodal recanalization therapy. Approximately 75% of the survivors have a favorable functional long-term outcome with an acceptable quality of life.

Fatigue at long-term follow-up in young adults with cerebral infarction.

BACKGROUND: To study the impact of fatigue in young ischaemic stroke patients. METHODS: The Fatigue Severity Scale score was obtained in 192 patients (mean time 6.0 years after the stroke) and 212 controls. RESULTS: Fatigue was associated with cerebral infarction in a multivariate analysis of patients and controls (p = 0.002). Fatigue was independently associated with unfavourable functional outcome (p = 0.001), depression (p < 0.001), and basilar artery infarction through interaction with the modified Rankin Scale score (p = 0.047) in patients. CONCLUSION: Fatigue is frequent in young adults with cerebral infarction. Stroke-related factors independently associated with fatigue include functional outcome. Stroke location may influence fatigue.

Effects of carotid or vertebrobasilar stent placement on cerebral perfusion and cognition.

INTRODUCTION: There are no well-established physiologic or neuropsychological criteria for identifying which patients with stenosis of the cervicocerebral vessels are at high risk of stroke or cognitive impairment. Our purpose was to evaluate changes in cognitive performance and cerebral perfusion associated with endovascular stent placement of the cervicocerebral vessels. METHODS: A consecutive series of 20 patients, 31-88 years of age, who underwent 21 stent procedures for arterial stenosis (10 extracranial carotid stents [ECS], four intracranial carotid stents [ICS], and seven extra- or intracranial vertebrobasilar stents [VBS]) was investigated retrospectively. All patients were evaluated with CT or MR perfusion studies both before and after stent placement. Cognitive response after stent placement was evaluated by using an informant questionnaire. RESULTS: In patients with anterior circulation stenoses (ECS and ICS group), 11 of 14 (79%) had a baseline perfusion abnormality and all 11 patients showed improved perfusion after stent placement. Four of seven (57%) patients with posterior circulation stenoses (VBS group) had a baseline perfusion abnormality and two of the four patients showed improved perfusion after stent placement. Degree of stenosis was the strongest predictor of the presence of a baseline perfusion abnormality (P = .03). Fifteen of 19 (79%) of the patients showed improved cognitive scores after stent placement. Among patients with improvement in perfusion after stent placement, 11 of 13 (85%) had improved cognitive scores. Improved perfusion after stent placement was a significant predictor of cognitive improvement (P = .04). Patients who were stented on an elective basis demonstrated greater improvement in cognition as compared with patients stented urgently (P = .01). CONCLUSION: Endovascular stent placement of the cervicocerebral vessels can safely and effectively resolve cerebral perfusion abnormalities. Improvement in perfusion parameters is associated with cognitive improvement. Larger, blinded, prospective studies are needed to confirm these preliminary observations.

Alteraciones neuropsicológicas en el ictus del territorio vertebrobasilar / Neuropsychological changes in ictus from vertebrobasilar area

Se realizó un estudio descriptivo prospectivo en 62 pacientes con ictus isquémico del territorio vertebrobasilar con el propósito de describir las alteraciones neuropsicológicas más frecuentes encontradas en ellos. La edad media del grupo fue de 59.8 años, predominó el sexo femenino (74.2 por ciento) y el color de piel blanca (77.4 por ciento). El factor de riesgo más frecuente fue la hipertensión arterial (48.4 por ciento), la diabetes mellitus se presentó en un porcentaje bajo (9,7 por ciento). El 67.7 por ciento de los pacientes presentó alteración del estudio neuropsicológico, el 38.7 por ciento tuvo adinamia cortical global, el 9.6 por ciento mostró disfunción temporal, un 6.5 por ciento afectación parietoccipital y un 12.9 por ciento presentó disfunción frontal. El 77.4 por ciento presentó lesión isquémica de región infratentorial y el 22.6 por ciento de estructuras supratentoriales del territorio posterior. Dentro de los complementarios a destacar se encuentra la Tomografía Axial Computarizada que reveló Ictus isquémico en 54.8 por ciento de los pacientes y el doppler de troncos supraaórticos, evidenciaron en el 58 por ciento de los casos enlentecimiento del flujo o aumento de la resistencia en la circulación vertebrobasilar(AU)

[Subclinical attention changes in transient ischemic attacks in the vertebrobasilar region]. / Alteraciones subclínicas de la atención en accidentes isquémicos transitorios de la región vertebrobasilar.

INTRODUCTION: A significant number of patients who have had cerebrovascular illness apparently recover their former abilities completely but return to normal life with subtle cognitive deficits which may affect their daily lives. Such is the situation of patients with transitory ischemic accidents who present with sustained, undiagnosed attention deficits. OBJECTIVES: To identify subclinical alterations due to attention deficits in patients with transitory ischemic accidents, and to contribute to the study of the physiopathological mechanisms involved in the integration of this function. PATIENTS AND METHODS: We examined 44 persons, divided into three groups for this study: one group had vertebro-basilar transitory ischemic accidents, a second group had supratentorial infarct and a third was healthy. All were given a specially designed computerized test of continuous work to evaluate the sustained attention component. RESULTS: Significant differences were found between the transitory ischemic accidents and healthy groups, regarding the variables including correct answers, omissions and indications of attention. This was not seen with the variables involving reaction time and number of errors. This demonstrated the existence of attention disorders involving omission in the group of patients with transitory ischemic accidents. CONCLUSION: These findings suggest the hypothesis that in the vertebro-basilar region there are important mechanisms involved in the process of sustained attention.

[Treatment of patients with thromboses of the basilar artery and locked-in syndrome. An ethical dilemma]. / Die Behandlung von Patienten mit Thrombosen der Arteria basilaris und Locked-in-Syndrom. Ein ethisches Dilemma.

Decisions regarding the extent of treatment of severely ill patients can be an ethical dilemma when life-prolonging intensive care contradicts the goal of avoiding unnecessary suffering on the part of the patient. Here we present the results of a written survey of physicians on neurological intensive care units in Germany regarding the treatment of patients with basilar artery thrombosis and locked-in syndrome. 52% of the 93 physicians who replied advocated not treating severe infections with antibiotics, 38% were in favor of stopping intensive care. In contrast, 55% recommended intubating the patient in the presence of swallowing disturbances and imminent aspiration. 58% were in favor of discussing these problems in detail with the patient, and 87% advocated discussing them with relatives. Nearly all physicians (97%) recommended using adequate amounts of opiates and benzodiazepines. In very rare cases, 99% would agree to the use of passive euthanasia and 19% to active euthanasia. These findings illustrate the current disagreement on some of the important treatment decisions among physicians on neurological intensive care units. An open exchange of views on these questions could facilitate the appropriate consideration of ethical matters in the treatment of these patients.

Can neuropsychological tests detect the sites of cerebrovascular stenoses and occlusions?

Conventional neuropsychological data may not mirror the site of cerebrovascular stenosis in a patient with mild to moderate symptoms. In this study, three groups of cerebral revascularization candidates failed to differ on an extended Halstead-Reitan battery: patients with symptoms and angiographic results referable to the carotid arterial system, subjects with clinical signs and neuroradiological findings referable to the vertebrobasilar arterial system, and patients with symptoms of cerebral ischemia but negative angiograms. Consistent with previous work, these patients generally were mildly impaired on neuropsychological tests, even though many were not symptomatic at the time of assessment. Neuropsychological tests seem to be sensitive to the presence and severity of cerebral ischemia, but in isolation may not be sufficient to determine the loci of vascular stenoses. The incongruence between angiographic and neuropsychological findings underlines the importance of distinguishing among different levels and types of measurements in defining subgroups of cerebral revascularization candidates. Collaboration among neuroscientists will further our understanding of the interrelationships among neurodiagnostic tests.

Neuropsychological changes associated with stenoses or occlusions of the carotid arteries. A comparative psychometric study.

A total of 33 patients with a relevant stenosis or occlusion of extracranial arteries were tested for a number of neuropsychological functions. Most of them [22] suffered from transient ischemic attacks, 6 from strokes, 5 were asymptomatic. Compared to an age-matched population of normals, patients showed an impairment in their mnemic functions, and attention under stress as well as in their psychomotor function. The degree of neuropsychological impairment was independent of the unilaterality or bilaterality of carotid stenoses. The results illustrate the neuropsychological deficit even in asymptomatic patients and those with complete recovery from transient neurological deficits.

The psychiatry of vertebro-basilar insufficiency with the report of a case.

Vertebro-basilar insufficiency produces a rich spectrum of psychological and neurological symptoms. Where psychological symptoms dominate the picture, the patient may be presented first to a psychiatrist. The phenomenology of vertebro-basilar insufficiency is discussed with special reference to hallucinatory syndromes, memory disturbance, affective disorders, akinetic mutism, 'unusual reports', cortical blindness, agitated delirium, the Capgras syndrome and normal pressure hydrocephalus. Finally, the case of a 61-year-old man illustrating a variety of the neurological and psychological features described in this paper is presented.

Preoperative neurobehavioral impairment in cerebral revascularization candidates.

We examined level of performance in 40 candidates for cerebral revascularization and found substantial variability on general indices of neuropsychological performance. Patients differed by duration of their longest ischemic attack, by surgery type, but not by time since onset of their first ischemic attack. Duration of the longest ischemic attack correlated highly with neuropsychological summary scores. In contrast, symptom duration was unrelated to level of performance in 18 additional patients with histories consistent with cerebrovascular ischemia who did not undergo surgery subsequently. We concluded that initial status on neuropsychological tests is an important variable to consider in postoperative followup of patients undergoing cerebral revascularization. More detailed clinical history and finer grained analysis of neuropsychological data promised to reveal additional relationships among clinical symptoms, neurobehavioral data, and underlying neuropathology.

Early auditory evoked potentials (EAEP) in vertebral basilar insufficiency.

Stimulation with a short tone pip elicits an acoustic nerve compound action potential (I) and different waves (II--VII) in the inital 10 ms. Seven waves have been studied in 40 control subjects and five waves in 12 patients with vertebral-basilar insufficiency. Abnormalities of the different waves were observed at levels such as cochlea and/or acoustic nerve, medulla, caudal pons, rostral pons, and midbrain. The recording of early auditory evoked potentials (EAEP) is a noninvasive method of confirming impairment of the auditory pathway caused by a reduced vascular supply of vertebral and basilar arteries.