Rotational Vertebrobasilar Insufficiency: Is There a Physiological Spectrum? Phase-Contrast Magnetic Resonance Imaging Quantification in Healthy Volunteers.

BACKGROUND: Some cases of cerebral ischemia have been attributed to dynamic flow limitation in neck vessels. It however remains unknown whether this represents the extreme end of a physiological response. METHODS: Eighteen healthy volunteers were recruited to this prospective study. Cervical blood flow (ml/min/m2) was assessed using phase-contrast MRI, and cerebral perfusion ratios were assessed using arterial spin labeling perfusion at neutral position, predefined head rotations, as well as flexion and extension. Inter-reader agreements were assessed using intraclass correlation coefficient. RESULTS: The mean age was 38.6 ± 10.8 (range = 22-56) years, for five male participants and 13 females. The means for height and weight were 168 cm and 73.2 kg, respectively. There were no significant differences in individual arterial blood flow with change in head position (P > 0.05). Similarly, the repeated-measures analysis of variance test demonstrated no significant difference in perfusion ratios in relation to head position movement (P > 0.05). Inter-reader agreement was excellent (intraclass correlation coefficient = 0.97). CONCLUSIONS: There is neither significant change in either individual cervical arterial blood flow nor cerebral perfusion within the normal physiological/anatomical range of motion in healthy individuals. It is therefore reasonable to conclude that any such hemodynamic change identified in a patient with ischemic stroke be considered causative.

Dynamic observation on collateral circulation construction of patient with vertebral artery restenosis after stenting: case report.

Purpose/aim of the study: Posterior circulation stroke (PCS) accounts for 20% of ischemic stroke, and vertebrobasilar stenosis is an important cause of PCS. Notably, not all patients with artery stenosis progress to ischemic stroke, and one of the important reason is that collateral circulation construction plays important protection role in this process.Clinical presentation: Here, we present the case of a 71-year-old male who presented with lightheadedness and three episodes of loss of consciousness after bilateral subclavian artery stenting. Digital subtraction angiography (DSA) demonstrated severe stenosis of the left vertebral artery, and the bilateral subclavian artery was kept open. The patient was then given the left vertebral artery stenting in an effort to resolve the vascular stenosis. As expected, he achieved a complete remission after stenting. However, 6 months later the patient suffered from loss of consciousness again. Repeat DSA confirmed restenosis of the left vertebral artery, and revealed a collateral flow to the left vertebral artery which fed by external carotid collateral branches. Then DSA was performed after 12 months, and another collateral circulation involving thyrocervical trunk was also found supplying flow to the left vertebral artery. In this process, the frequency of loss of consciousness gradually decreased as the collateral circulation construction. Conclusion: Through this case, we observe the whole process of the collateral circulation construction. Moreover, this case serves as a testament to the variability and complexity of vertebrobasilar arteriopathies, suggesting promotion of collateral flow offers the opportunity for outcome improvement.

The therapeutic effect and mechanism of Chinese medicine Xuan-Yun-Ding on posterior circulation ischemia with vertigo in a rabbit model.

The aim of research is to unveil the mechanisms of the beneficial effects of XYD on PCIV in a rabbit model. 40 New Zealand white rabbits were randomly divided into 5 groups,including normal control group (NC), model control group (MC), low-dose of XYD group (LXYD), high-dose of XYD group (HXYD) and Yang-Xue-Qin-Nao group (YXQN). PCIV rabbit model was established by feeding high-fat diet companied with paravertebral sclerotherapy and rotation exercise. The general observation, step-down test, rheoencephalogram, blood tests, histopathological detection and the plasma concentration of the effective component of XYD were investigated. After pharmacological intervening, the step-down time, REG, PL, IPL, blood viscosity, the levels of blood lipids, CRGP were significantly improved. Moreover, the vertebral artery showed the reduced stenosis of arterial lumen and less proliferation of fibrous tissue in the arterial wall in the LXYD, HXYD and YXQN group. Based on the LC-MS detection, the blood concentrations of puerarin in the LXYD and HXYD group were significantly increased after pharmacological intervening. XYD could ameliorate the symptoms of vertigo, Qi-deficiency and blood stasis in PCIV rabbits via effectively regulating the levels of blood lipids and vasoactive substances, decreasing blood viscosity, increasing CBF and protecting vestibular function.

Basilar dolichoectasia with intermural hematoma accompanied by cerebral microbleeds and white matter hyperintensities: A case report.

RATIONALE: The clinical manifestations of basilar dolichoectasia (BD) are variable. The diagnosis is based on imaging measurements. Digital subtraction angiography displays only the dilated vascular lumen and lacks visualization of the arterial wall. High-resolution Magnetic resonance imaging (MRI) can identify intramural hematoma; therefore, it may be more suitable for the imaging evaluation of BD. However, most of the existing literature pertaining to BD lacks vascular wall assessment. PATIENT CONCERNS: A 65-year-old Chinese man perceived weakness of the left upper and lower limb, double vision, dizziness, nausea, and vomiting was admitted to the emergency department. Fifteen years prior to this admission, he began taking levamlodipine besylate inconsistently for hypertension, but the level of blood pressure control was uncertain. The patient's father had a family history of hypertension. DIAGNOSES: An emergency axial computed tomography scan of the brain showed basilar artery (BA) dilation. Computed tomography angiography further indicated a maximum BA diameter of 38.94 mm. The length was >182 mm. MRI revealed acute infarctions of the right medulla oblongata and pons. Meanwhile, the patient had evidence of cerebral small vessel disease, including cerebral microbleeds and white matter hyperintensities. Whole-exome sequencing eliminated significant genetic variations consistent with clinical phenotypes. BD and intramural hematoma were further confirmed by high-resolution MRI of the arterial wall. INTERVENTIONS: Atorvastatin was admitted according to the results of the high-resolution MRI of the arterial wall. Benidipine hydrochloride was selected as a long-term anti-hypertensive drug. OUTCOMES: The patient had no symptoms of neurological damage during 3-month follow-up. LESSONS: Current evidence shows that BD has no obvious correlation with atherosclerosis. BA dissection and uncontrolled hypertension may be important factors in the progression of BD. BD-related stroke is likely to recur, and there are no standard secondary prevention measures. BD is often accompanied by cerebral microbleeds, and bleeding risk must be assessed during secondary prevention. When the BA diameter is greater than 10 mm, anti-platelet medication should be used with caution, blood pressure should be strictly controlled, and endovascular treatment should be considered.

Risk factors associated with recurrence of ischemic stroke after intracranial stenting in china: a case-control study.

Objectives: To investigate the factors affecting the risk of recurrent stroke after intracranial artery stenting.Methods: This is a subgroup analysis of a prospective single-arm registry study with 20 participating sites. Patients aged 18-85 years old with symptomatic intracranial atherosclerotic stenosis caused by 70-99% stenosis combined with poor collaterals were included in this study. The median follow-up in this study was 26.4 months.Results: A total of 260 patients were recruited in this study. Ischemic stroke related to target vessel occurred in 11 patients (4.2%) from 30 days to the last follow-up. The multivariate analysis revealed age ≥60 years old (OR: 11.991, 95% CI: 1.400-102.716; p = 0.023), no smoking (OR: 0.087, 95% CI: 0.010-0.787; p = 0.030), and Mori C type (OR: 5.129, 95% CI: 1.242-21.178; p = 0.024) retained significance in the model. There was no significant difference in the ischemic stroke based on medical history of hypertension, diabetes, dyslipidemia, baseline percent stenosis, length of stenosis, residual stenosis, and different stent types.Conclusions: Recurrence of ischemic stroke after intracranial stenting may be associated with elderly age, non-smoking, and Mori C type lesion. These factors will need to be monitored in future trials of intracranial stenting.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01968122.

Superficial Temporal Artery-Posterior Cerebral Artery Bypass for the Treatment of Chronic Basilar Artery Occlusion.

OBJECTIVE: To investigate the effect of superficial temporal artery-posterior cerebral artery (STA-PCA) bypass on chronic basilar artery occlusion (CBAO). METHODS: A total of 4 patients who underwent STA-PCA bypass between January 2018 and October 2019 were enrolled in this study. Cerebral blood perfusion, ischemic events, STA diameter and blood flow changes, modified Rankin scale score (mRS), and National Institutes of Health Stroke Scale (NIHSS) score changes were recorded before and after bypass surgery. RESULTS: The average time from basilar artery occlusion (confirmed by cerebral angiography or computed tomography angiography) to operation was 76 ± 38.89 days (range: 30-120 days). Average scores on the NIHSS were 6.8 ± 1.26 (5-8) and 5.2 ± 2.06 (3-7) before and after treatment, respectively. mRS scores averaged 1.8 ± 0.5 (1-2) and 1.5 ± 0.58 (1-2) points, respectively. There were no obvious complications or further stroke during the follow-up. The STA diameter and flow rate were significantly increased at 12 months after operation (P < 0.05). CONCLUSIONS: STA-PCA bypass can improve cerebral blood flow perfusion in CBAO patients. The diameter and flow of the superficial temporal artery can be increased to meet the demand of blood supply.

Validation of a Polish version of the Israeli Vertebrobasilar Stroke Scale - An attempt to more accurately assess posterior Stroke.

OBJECTIVE: Posterior circulation stroke, in contrast to anterior circulation stroke, has a greater complexity and variability of clinical symptoms. This could be responsible for delayed diagnosis and treatment time and, as a consequence, worse prognosis. Certain blame in this respect can also be attributed to the clinimetric scales used to assess stroke severity, which are characterized by significantly lower accuracy than with anterior strokes. The Israeli Vertebrobasilar Stroke Scale (IVBSS) was the first attempt dedicated to posterior strokes and was devised for better measurement of clinical condition. We aimed to develop a Polish version of the IVBSS (PL-IVBSS) to assess the reliability, validity and psychometric properties of the tool to confirm its clinical utility. METHODS: We enrolled 126 posterior circulation ischemic stroke subjects. Four researchers estimated stroke severity using appropriate and widely accepted devices (the modified Rankin Scale - mRS, the National Institutes of Health Stroke Scale - NIHSS, the Barthel Index, and the Glasgow Coma Scale - GCS) and compared with the PL-IVBSS. We analyzed inter- and intrarater agreements, repeatability, concurrent and predictive validity, internal consistency, scalability and homogeneity, reflecting the psychometric features of a validated instrument. RESULTS: Cronbach's alpha coefficient was 0.67, and the median inter-item correlation coefficient was 0.22, indicating moderate internal consistency and insufficient homogeneity. A total of 63.6% of the individual items obtained required discriminatory power (r > 0.3), showing moderate scalability. The PL-IVBSS achieved a good coefficient of repeatability (CR = 1.21 95%CI 1.08-1.38) and narrow limits of agreement in Bland-Altman analysis, emphasizing the accuracy and high reproducibility. Excellent intraclass correlation coefficients and weighted kappa values (all >0.90) underlined the high reliability of the PL-IVBSS. Highly significant correlations with other relevant devices (all r > 0.5, p < 0.0001) highlighted the satisfactory concurrent and predictive validity of a validated clinimetric tool. CONCLUSION: We devised a validated version of the IVBSS, indicating the high reproducibility, repeatability and accuracy of the PL-IVBSS and confirming its clinical utility. Despite moderate psychometric properties, our findings support the need for its clinical application and widespread use in stroke units for a reliable assessment of posterior stroke severity.

Impact of the Perioperative Blood Pressure on Clinical Outcome after Thrombectomy in Acute Basilar Artery Occlusion.

AIM: Optimal blood pressure (BP) management in vertebrobasilar circulation stroke patients undergoing thrombectomy remains undetermined. We aimed to evaluate the impact of perioperative BP on clinical outcome after MT in acute basilar artery occlusion (BAO) patients. METHODS: We retrospectively analyzed all consecutive patients hospitalized with acute basilar artery occlusion administered endovascular treatment within 24 h from January 2012 to July 2018 in Beijing Tiantan Hospital. BP was measured at regular intervals during the first 24 h after stroke onset, during and after thrombectomy. The clinical outcomes assessed at 3-month follow up were functional independence (mRS score of 0-2) and mortality (mRS score of 6). RESULTS: Of the 187 treated patients, 157 were male; patient ages were 60±10 years. The median NIHSS on admission was 22. Totally in 179 patients had complete BP level assessment. In these individuals, univariate analysis revealed significant associations of postoperative Max SBP and Max MAP with mortality (all P < 0.05). Multivariate regression analysis also demonstrated that postoperative Max SBP (OR=0.964, 95% CI 0.941 to 0.987, P < 0.003) and Max MAP (OR=0.942, 95% CI 0.907 to 0.979, P < 0.002) were independent predictors of mortality. CONCLUSIONS: In acute BAO patients administered thrombectomy, Max SBP between 120 and 160 mmHg may be associated with better outcome, with a trend of reduced risk of mortality.

Vertebral artery stenosis.

Symptomatic vertebral artery stenosis is associated with high risk of early recurrent stroke. Vertebral artery stenosis can be treated with angioplasty and stenting with good technical results. In this review we outline the framework for the diagnosis and management of vertebral artery disease with focus on the emerging benefits of angiography and endovascular interventions.

Characteristics and prognosis of acute basilar artery occlusion in minor to moderate stroke and severe stroke after endovascular treatment: A multicenter retrospective study.

OBJECTIVE: We aimed to investigate characteristics and outcomes of patients receiving mechanical thrombectomy (MT) between minor to moderate stroke and severe stroke caused by acute basilar artery occlusion (BAO). METHODS: We retrospectively reviewed the data of all patients with BAO who underwent MT from three stroke centers between January 2016 and January 2020. The patients were dichotomized as minor to moderate or severe stroke group according to their admission National Institutes of Health Stroke Scale (NIHSS) score <21and ≥21. Patient characteristics, imaging findings, and outcomes were compared between the two groups. RESULTS: A total of 72 patients were included in this study. The posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) in the minor to moderate stroke patients were significantly higher than that of patients with severe stroke (P = 0.013). The good posterior circulation collateral scores (PC-CS) (6-10) were more commonly found in patients with minor to moderate stroke than in patients with severe stroke (58.14 % vs 10.34 %,P < 0.001). There were similar rates of successful recanalization between the two groups. Patients with minor to moderate stroke had a higher rate of favorable outcomes (mRS score 0-2, 60.47 % vs 20.69 %, P = 0.002) and a lower rate of periprocedural complications (4.65 % vs 31.03 %, P = 0.005) and mortality (4.65 % vs 24.14 %, P = 0.026) at 3 months after MT compared with the patients with severe stroke. CONCLUSIONS: Acute BAO patients with minor to moderate stroke had better posterior circulation collateral and had better outcomes after MT than those patients with severe stroke.

Direct ultrasound-guided puncture of vertebral artery V2 segment during mechanical thrombectomy.

An 83-year-old man experienced left upper limb uncontrolled movements preceded by intense gasping during night rest, which progressed to unconsciousness and respiratory arrest requiring intubation. He was diagnosed with acute stroke due to distal occlusion of the basilar artery and received indication for endovascular thrombectomy. Standard endovascular approach includes percutaneous puncture of the femoral or radial arteries; however, the presence of unfavourable vascular anatomies (stenotic origin and tortuosity) did not allow catheterisation of the intracranial vessels through conventional access, and based on the consistent time lapse from onset of symptoms and deterioration of the clinical condition, a direct right vertebral artery ultrasound-guided puncture was performed. After one attempt of a triaxial technique, a complete recanalisation of the basilar artery and of its distal branches was achieved. Direct percutaneous puncture of the vertebral artery represents a rescue access strategy for treatment of posterior circulation stroke when other routes are not feasible.

Relationship Between Acute Neurological Function and Long-Term Prognosis in Patients with Large Arterial Occlusions.

OBJECTIVES: To clarify the relationship between early neurological symptoms and long-term functional outcomes of acute ischemic stroke, which would be beneficial for patient management and determining clinical study criteria of novel therapeutic interventions. MATERIALS AND METHODS: We retrieved data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) and investigated the association between 24- and 72-hour National Institutes of Health Stroke Scale (NIHSS) and 90-day modified Rankin Scale (mRS) scores, stratified by the site of occlusion (carotid or vertebrobasilar circulatory large arterial occlusion [ACO or PCO, respectively]) and endovascular recanalization therapy (EVT) performance. We examined the correlation using Spearman's rank correlation coefficient (rho). Predictive accuracies of 24- and 72-hour NIHSS scores for good outcomes at 90 days (defined as mRS score of 0-2) were evaluated by receiver operating characteristic (ROC) analyses and the corresponding areas under the curves (AUCs). RESULTS: Among the 2420 patients, 1745 had ACO (971 with EVT, 774 without EVT) and 263 had PCO (127 with EVT, 136 without EVT). The 24- and 72-hour NIHSS scores were significantly associated with 90-day mRS scores and accurately predicted good outcomes (all rhos ≥0.76, all AUCs ≥0.86). In the ACO group, there were differences in rho and AUC depending on EVT performance and the time from onset to NIHSS acquisition, but no differences were observed in the PCO group. CONCLUSIONS: EVT performance and time frame should be considered when determining the criteria of novel therapeutic interventions, especially for patients with ACO.

Reproducible Presyncope Due to Osteophyte Compression Into Transverse Foramen of the C5 Vertebra.

Beauty parlor stroke syndrome is characterized by the development of various neurological symptoms during cervical hyperextension, followed by inadequate blood flow through the posterior circulation of the brain. However, there are few reports of beauty parlor stroke syndrome wherein the cause of the posterior circulatory inadequacy has been directly identified. Here we report a case where we could directly detect the origin of the posterior circulatory inadequacy. A 76-year-old Japanese man with hypertension presented with presyncope following cervical retroflexion. Head magnetic resonance angiography revealed that the vertebrobasilar circulation was exclusively supplied by the right vertebral artery. Cervical spine computed tomography showed compression of the osteophytes on the right superior articular process of C6 into the right transverse foramen of C5. Moreover, computed tomography angiography and carotid duplex ultrasonography showed decreased blood flow in the right vertebral artery on gradual retroflexion of the neck. Based on the above findings, we speculate that the right vertebral artery was compressed by the osteophytes, with the decreased blood flow being the cause of presyncope following cervical retroflexion.

Endovascular Treatment of Symptomatic Intracranial Vertebrobasilar Stenosis: A 10-Year Single Centre Experience Using Balloon-Expandable Coronary Artery Stents.

BACKGROUND: Symptomatic intracranial vertebro-basilar stenoses (SIVBS) are associated with high risk of recurrent ischemic stroke, even in patients receiving the best medical treatment. Although medical treatment is still the standard of care, non-responding patients may require endovascular treatment; balloon-mounted coronary stents (BMCS) could be successfully employed. This study aims to retrospectively analyze our high volume Interventional Neurovascular center ten-year experience in the off-label use of BMCS for the treatment of SIVBS, in order to assess its feasibility and safety. METHODS: We retrospectively analyzed all consecutive patients with SIVBS treated with BMCS in the last ten years in our center. Data collected included patient demographics, stenosis location and characteristics, early (<30 days) and late (>30 days) stroke and death rates, pre-symptomatic and post-treatment modified Rankin Scale (mRS) scores. RESULTS: 42 patients (35 males, average age 65,7 ± 10,7, range 37-85) with SIVBS were treated with BMCS. Thirty-four (80,9%) patients were symptomatic despite ongoing best medical therapy; eight (19,1%) patients were treated in emergency for large vessel occlusion, due to an underlying stenosis. BMCSs were successfully deployed in all cases. The incidence of stroke and death at one month was 7,1% (3/42). The incidence of TIA, stroke and death at long-term follow-up (average time of 3 years) was 14,3% (4,7 per 100 person-years). At long-term follow-up, mRS improved in 82% of patients who underwent elective treatment. CONCLUSIONS: In our experience, the off-label use of BMCS in the endovascular treatment of SIVBS resistant to medical treatment is feasible and safe.

Absence of pontine perforators in vertebrobasilar dolichoectasia on ultra-high resolution cone-beam computed tomography.

BACKGROUND: Vertebrobasilar dolichoectasia (VBDE) is a rare type of non-saccular intracranial aneurysm, with poor natural history and limited effective treatment options. Visualizing neurovascular microanatomy in patients with VBDE has not been previously reported, but may yield insight into the pathology, and provide important information for treatment planning. OBJECTIVE: To carry out a retrospective analysis of ultra-high resolution cone-beam computed tomography (UHR-CBCT) in patients with fusiform basilar aneurysms, visualizing neurovascular microanatomy of the posterior circulation with a special focus on the pontine perforators. METHODS: UHR-CBCT was performed in seven patients (mean age 59 years; two female) with a VBDE, and in 14 control patients with unrelated conditions. RESULTS: The mean maximum diameter of the fusiform vessel segment was 28 mm (range 19-36 mm), and the mean length of the segment was 39 mm (range 15-50 mm). In all patients with VBDE, UHR-CBCT demonstrated an absence of perforating arteries in the fusiform arterial segment and a mean of 3.7 perforators arising from the unaffected vessel segment. The network of interconnected superficial circumferential pontine arteries (brainstem vasocorona) were draping around the aneurysm sac. In controls, a mean of 3.6, 2.5, and 1.2 perforators were demonstrated arising from the distal, mid-, and proximal basilar artery, respectively. CONCLUSIONS: The absence of pontine perforators in the fusiform vessel segment of VBDE is counterbalanced by recruitment of collateral flow from pontine perforators arising from the unaffected segment of the basilar artery, as well as collaterals arising from the anterior inferior cerebellar artery/posterior inferior cerebellar artery and superior cerebellar artery. These alternative routes supply the superficial brainstem arteries (brainstem vasocorona) and sustain brainstem viability. Our findings might have implications for further treatment planning.

Endovascular Treatment for Vertebrobasilar Artery Tandem Occlusion Beyond 24 Hours From Onset of Stroke-Case Report.

We report a case in which endovascular treatment (EVT) was performed for vertebral and basilar artery (VA and BA) tandem occlusion beyond 24 hours from onset of stroke. A 78-year-old man was admitted to our institution with dysarthria and disturbance of gait. MRI revealed occlusion of the BA with acute ischemic change in bilateral cerebellum and brain stem. At 36 hours after onset and 30 hours after administration, EVT was performed because of deteriorating neurological symptom. Successful revascularization was achieved with percutaneous transluminal angioplasty for VA and thrombectomy for BA occlusion. The neurological symptoms were improved in postoperative course.

Perfusion-MRI is a Poor Indicator of Hemodynamic Compromise in Vertebrobasilar Disease in the VERiTAS Study.

BACKGROUND AND PURPOSE: Dynamic susceptibility perfusion MR imaging (DSC MRP) has been used to assess changes in cerebral perfusion attributable to vascular stenosis or occlusion that may predict stroke risk. However, DSC MRP is not validated for identifying hemodynamic compromise in the posterior circulation. We investigated the clinical utility of DSC MRP in vertebrobasilar (VB) atherosclerotic disease in the observational VERiTAS study. METHODS: VERiTAS enrolled patients with symptomatic ≥50% VB stenosis/occlusion. Posterior circulation hemodynamic status was designated as low or normal based on large vessel flow measured using quantitative magnetic resonance angiography (QMRA) and was predictive of future stroke risk. In this study, DSC MRP conducted concurrently with QMRA was used to evaluate posterior circulation perfusion. The primary outcome was the mean transit time (MTT) and relative cerebral blood volume (rCBV) in the posterior circulation normalized to the anterior circulation, compared between patients with low and normal blood flow as determined on QMRA. RESULTS: Twenty-six subjects had 47 DSC MRP studies for review. There was no statistically or clinically significant difference in the rCBV ratio (1.02 vs. .96 P = .89), or MTT ratio (1.04 vs. 1.04 P = .96) relative to normal or low VB territory flow. CONCLUSIONS: In this study, we did not find that DSC MRP adequately distinguished between patients with low or normal flow status based on large-vessel flow measurements.

Treatment Outcomes by Initial Neurological Deficits in Acute Stroke Patients with Basilar Artery Occlusion: The RESCUE Japan Registry 2.

BACKGROUND AND PURPOSE: We hypothesized that the relationships between treatments and outcomes in acute basilar artery occlusion (BAO) are different, depending on the severity of initial neurological deficits. METHODS: Of 2420 ischemic stroke patients with large vessel occlusion in a prospective, multicenter registry in Japan, patients with acute BAO were enrolled. Subjects were divided into two severity groups according to the baseline NIH Stroke Scale score: severe (≥10) and mild (<10) groups. The primary effectiveness outcome was favorable outcome, defined as modified Rankin Scale score 0-3 at 3 months. Safety outcomes included any intracranial hemorrhage (ICH) within 72 h. Outcomes in each group were compared between patients who received endovascular therapy (EVT) and those with standard medical treatment (SMT). RESULTS: In this study, 167 patients (52 female; median age 75 years) were analyzed. The favorable outcome was seen in 93 patients (56%) overall. In the severe group (n = 128), the proportion of favorable outcome was higher in patients who received EVT (60/111, 54%) than those with SMT (2/17, 12%, P < 0.01). In the mild group (n = 39), the rates of favorable outcome were comparable between the EVT (13/18, 72%) and SMT patients (18/21, 86%, P = 0.43). No significant differences in the rates of any ICH were seen among any groups. CONCLUSIONS: In acute BAO stroke with severe neurological deficit, independent ambulation was more frequently seen in patients who received EVT than those with SMT. Patients with mild neurological deficits showed similar rates of independent ambulation between the two treatment selections.

Natural History of Hemodynamics in Vertebrobasilar Disease: Temporal Changes in the VERiTAS Study Cohort.

BACKGROUND AND PURPOSE: The role of regional hypoperfusion as a contributor to stroke risk in atherosclerotic vertebrobasilar disease has recently been confirmed by the observational VERiTAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) Study. We examined the stability of hemodynamic status over time and its relationship to stroke risk in patients from this prospective cohort. METHODS: VERiTAS enrolled patients with recently symptomatic ≥50% atherosclerotic stenosis/occlusion of vertebral and/or basilar arteries. Large vessel flow in the vertebrobasilar territory was assessed using quantitative magnetic resonance angiography, and patients were designated as low or normal flow based on distal territory regional flow, incorporating collateral capacity. Patients underwent standard medical management and follow-up for primary outcome event of vertebrobasilar territory stroke. Quantitative magnetic resonance angiography imaging was repeated at 6, 12, and 24 months. Flow status over time was examined relative to baseline and relative to subsequent stroke risk using a cause-specific proportional hazard model, with flow status treated as a time-varying covariate. Mean blood pressure was examined to assess for association with changes in flow status. RESULTS: Over 19±8 months of follow-up, 132 follow-up quantitative magnetic resonance angiography studies were performed in 58 of the 72 enrolled patients. Of the 13 patients with serial imaging who had low flow at baseline, 7 (54%) had improvement to normal flow at the last follow-up. Of the 45 patients who had normal flow at baseline, 3 (7%) converted to low flow at the last follow-up. The mean blood pressure did not differ in patients with or without changes in flow status. The time-varying flow status remained a strong predictor of subsequent stroke (hazard ratio, 10.3 [95% CI, 2.2-48.7]). CONCLUSIONS: There is potential both for improvement and worsening of hemodynamics in patients with atherosclerotic vertebrobasilar disease. Flow status, both at baseline and over time, is a risk factor for subsequent stroke, thus serving as an important prognostic marker. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT00590980.