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2.
J Stroke Cerebrovasc Dis ; 29(2): 104504, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31761735

RESUMO

BACKGROUND: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. METHODS: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. RESULTS: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). CONCLUSIONS: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.


Assuntos
Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Infarto da Artéria Cerebral Anterior/epidemiologia , Infarto da Artéria Cerebral Média/epidemiologia , Insuficiência Vertebrobasilar/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Artéria Cerebral Anterior/diagnóstico por imagem , Artéria Cerebral Anterior/fisiopatologia , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/fisiopatologia , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Angiografia Cerebral/métodos , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Feminino , Humanos , Infarto da Artéria Cerebral Anterior/diagnóstico por imagem , Infarto da Artéria Cerebral Anterior/fisiopatologia , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/fisiopatologia , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/fisiopatologia , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos/epidemiologia , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/fisiopatologia , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/fisiopatologia
3.
BMC Med Imaging ; 19(1): 99, 2019 12 26.
Artigo em Inglês | MEDLINE | ID: mdl-31878890

RESUMO

BACKGROUND: The relationship between intracranial vessel configuration and wall features remains poorly investigated. Therefore, we aimed to investigate the relationship between the distal and proximal anatomical configuration of basilar artery (BA) and BA vessel wall features on high-resolution magnetic resonance imaging (HRMRI). METHODS: From September 2014 to January 2017, patients with suspected symptomatic intracranial arterial stenosis underwent HRMRI. Patients with severe BA stenosis were selected for this prospective study and divided into two groups corresponding to complete and incomplete BA configuration based on characteristics of the bilateral vertebral arteries and posterior cerebral arteries. Culprit blood vessel wall features on HRMRI included plaque enhancement, intraplaque hemorrhage, remodeling patterns, and plaque distribution. Culprit vessel wall features were compared between patients in the complete and incomplete BA configuration groups. RESULTS: Among the 298 consecutively enrolled patients, 34 had severe BA stenosis. Twenty patients had complete anatomical BA configuration and another 14 of them displayed incomplete configuration. There were no significant differences in vessel wall features between the complete and incomplete configuration patient groups. However, the proximal configuration of BA was associated with intraplaque hemorrhage (p = 0.002) while the distal configuration of BA correlated with strong enhancement of BA plaque (p = 0.041). CONCLUSIONS: No association was found between the complete and incomplete BA configuration groups and blood vessel wall features. The proximal configuration of BA was related with intraplaque hemorrhage and the distal configuration of BA was associated with strong plaque enhancement. Further studies are warranted to confirm these findings. TRIAL REGISTRATION: URL: Unique identifier: NCT02705599 (March 10, 2016).


Assuntos
Artéria Basilar/patologia , Imagem por Ressonância Magnética/métodos , Insuficiência Vertebrobasilar/diagnóstico por imagem , Idoso , Artéria Basilar/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade , Insuficiência Vertebrobasilar/patologia
4.
BMJ Case Rep ; 12(8)2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31377714

RESUMO

There is limited literature on the use of mechanical thrombectomy with stent-retrievers in paediatric stroke, especially in the posterior circulation. We report a paediatric case of acute basilar artery occlusion successfully treated by mechanical thrombectomy using stent-retriever but complicated by delayed basilar artery stenosis. This case emphasises prudent selection of thrombectomy device and meticulous long-term follow-up when employed in paediatric stroke.


Assuntos
Arteriopatias Oclusivas/terapia , Artéria Basilar/cirurgia , Trombectomia/instrumentação , Insuficiência Vertebrobasilar/diagnóstico por imagem , Criança , Humanos , Angiografia por Ressonância Magnética , Masculino , Trombectomia/efeitos adversos , Resultado do Tratamento , Insuficiência Vertebrobasilar/etiologia
5.
BMJ Case Rep ; 12(7)2019 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-31340945

RESUMO

Bow Hunter's syndrome (BHS) is a rare cause of vertebrobasilar insufficiency and is reported to most commonly be caused by vertebral artery impingement on cervical vertebrae osteophytes. We report a case in a 56-year-old male patient who on investigation of recurrent posterior circulation ischaemic strokes was found to have BHS. The aetiology of the syndrome in this patient is due to a particularly unusual aberrancy in the path of the atlantoaxial portion of the culprit left vertebral artery. Aberrancy of the distal portion of the vertebral artery is in itself a rare entity, and there are few reports of it in relation to BHS. The patient in this case was successfully treated with endovascular sacrifice of the vertebral artery with no further dynamic occlusive symptoms.


Assuntos
Angiografia por Ressonância Magnética/métodos , Artéria Vertebral/anormalidades , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/tratamento farmacológico , Angiografia Cerebral/métodos , Tratamento Conservador , Diagnóstico Diferencial , Tontura/diagnóstico , Tontura/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Náusea/diagnóstico , Náusea/etiologia , Medição de Risco , Síndrome , Artéria Vertebral/diagnóstico por imagem , Insuficiência Vertebrobasilar/diagnóstico , Transtornos da Visão/diagnóstico , Transtornos da Visão/etiologia
6.
BMC Neurol ; 19(1): 163, 2019 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-31315603

RESUMO

BACKGROUND: Patients with vertebrobasilar dolichoectasia usually have persistent hemodynamic abnormalities, and therefore, may bear an increased risk of stroke. This study aimed to identify risk factors for stroke recurrence in patients with vertebrobasilar dolichoectasia. METHODS: Patients with acute ischemic stroke were screened and evaluated for eligibility. Enrolled patients were followed via scheduled clinical visits or telephone interviews. Ischemic stroke recurrence was proposed with clinical symptoms and confirmed with cranial Magnetic Resonance Imaging or Computerized Tomography scans. Baseline characteristics and vascular geometry were compared between patients with and without stroke recurrence. Significant parameters were introduced into COX proportional hazard model to detect possible predictors of stroke recurrence. RESULTS: A total of 115 stroke patients with vertebrobasilar dolichoectasia were enrolled, of which 22 (19.1%) had recurrence during 22 ± 6 months follow-up. Basilar artery diameter ≥ 5.3 mm (HR = 4.744; 95% CI, 1.718-13.097; P = 0.003), diffuse intracranial dolichoectasia (HR = 3.603; 95% CI, 1.367-9.496; P = 0.010) and ischemic heart disease history (HR = 4.095; 95% CI, 1.221-13.740; P = 0.022) had increased risk of recurrence. CONCLUSIONS: Stroke patients with vertebrobasilar dolichoectasia may have a high risk of recurrence. Larger basilar artery diameter or diffuse intracranial dolichoectasia may increase the risk of recurrence.


Assuntos
Artéria Basilar/patologia , Acidente Vascular Cerebral/etiologia , Insuficiência Vertebrobasilar/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Artéria Basilar/diagnóstico por imagem , Isquemia Encefálica/complicações , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Recidiva , Fatores de Risco , Tomografia Computadorizada por Raios X , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/patologia
7.
J Neurointerv Surg ; 11(11): 1162-1166, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31197025

RESUMO

OBJECTIVES: To characterize the safety and efficacy of large woven stents in the treatment of vertebrobasilar dolichoectasia (VBD). METHODS: We retrospectively reviewed 19 consecutive patients with VBD treated with large woven intracranial stent (Leo stents) between January 2016 and December 2018. The clinical symptoms and angiograms of all the patients were recorded. RESULTS: The patients were treated with 1-3 large Leo stents (5.5 mm x 75 mm, 5.5 mm x 50 mm, or 4.5 mm x 40 mm), with or without coiling. They had follow-up angiography and MRI between 3 months and 1 year. Digital subtraction angiography showed 16 patients with complete reconstruction of the target vessels, one patient with almost complete reconstruction, and two patients with partial reconstruction. All patients had symptomatic improvement shortly after treatment, but two patients developed recurrent dysphagia at 8 and 18 months, respectively. CONCLUSIONS: Deployment of woven stents with or without supportive coiling may offer symptom relief and reconstruction in patients with VBD.


Assuntos
Procedimentos Endovasculares/instrumentação , Stents Metálicos Autoexpansíveis , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/terapia , Idoso , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents Metálicos Autoexpansíveis/efeitos adversos , Resultado do Tratamento
8.
Cerebrovasc Dis Extra ; 9(2): 46-56, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31167189

RESUMO

BACKGROUND: Acute basilar artery occlusion (BAO) is a devastating condition if untreated. The optimal treatment strategy, however, is unknown. Historically, interventional approaches have been favored over intravenous thrombolysis (IVT), although this is not supported by good evidence. The aim of this systematic review and meta-analysis was to summarize and compare the results for treatment modalities of BAO, namely, IVT and interventional stent retriever thrombectomy (SRT). METHODS: Studies on IVT and SRT in BAO were systematically searched. Successful recanalization (TICI ≥2b), favorable clinical outcome (modified Rankin Scale score ≤2), mortality, and the rate of symptomatic intracranial hemorrhage (SICH) were the target parameters. Only studies with ≥15 patients were included. IVT prior to SRT was allowed. Studies were excluded (1) if >1 thrombectomy device was used in >50% of the patients and (2) when data on outcome or treatment could not be parsed (e.g. registries). Odds ratios (ORs) were calculated using Mantel-Haenszel risk ratio estimation. Results are given as OR and the 95% confidence interval (95% CI). The χ2 test was used to compare the outcome parameters clinical outcome, recanalization, mortality, and SICH. RESULTS: A total of 17 studies (4 on IVT and 13 on SRT) with a total of 672 patients (IVT, n = 314; SRT, n = 358) were identified. Cumulatively, we found a highly significantly improved clinical outcome (43 vs. 31%, p = 0.004, OR [95% CI] = 1.66 [1.21, 2.76]), increased recanalization rate (88 vs. 60%, p < 0.00001, OR [95% CI] = 3.99 [2.73, 5.84]), and decreased mortality (26 vs. 41%, p = 0.0004, OR [95% CI] = 1.86 [1.33, 2.61]), as well as an equal rate of SICH (5 vs. 7%, p = 0.15, OR [95% CI] = 1.68 [0.82, 3.43]), in patients treated with SRT compared to those treated with IVT alone. CONCLUSIONS: The data from this meta-analysis suggest a possible superiority of SRT over IVT, pending positive results of randomized controlled trials. According to international recommendations, patients with BAO should preferentially be treated with SRT; if no contraindications exist, IVT should not be withheld.


Assuntos
Fibrinolíticos/administração & dosagem , Stents , Trombectomia/instrumentação , Terapia Trombolítica , Insuficiência Vertebrobasilar/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do Tratamento , Grau de Desobstrução Vascular , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/mortalidade , Insuficiência Vertebrobasilar/fisiopatologia
9.
Neurol Sci ; 40(10): 2007-2015, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31127426

RESUMO

Posterior circulation strokes affect the vertebrobasilar arterial system, account for about 20-25% of all ischemic strokes, and are a significant cause of patient disability and mortality. Diagnosis can be challenging; clinical presentation and common pitfalls facing posterior circulation stroke have been discussed elsewhere. In the first part of the review, we focus on the imaging, discussing the information that can be gathered through a correct selection and interpretation of different possible studies helping to achieve an early diagnosis and to select the best medical treatment. In the second part of the review, we will discuss the best therapeutic treatments available at the moment for posterior circulation ischemia.


Assuntos
Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/terapia , Humanos
10.
Neurochirurgie ; 65(4): 191-194, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31095942

RESUMO

A review of the literature revealed that basilar artery (BA) entrapment is a very rare (17 cases published) and severe pathological condition, which often leads to death. We report the case of a 72-year-old man who presented with a longitudinal clivus fracture associated with a basilar artery entrapment. This entrapment was responsible for a basilar artery dissection, which led to an ischemic stroke in the pons. The patient was managed with medical treatment, mainly to avoid a progression towards an ischemic stroke. It consisted of heparin therapy followed by antiplatelet therapy, which finally resulted in a successful outcome. In BA entrapment most of the patients who had a favorable outcome received antithrombotic therapy. This suggests that antithrombotic therapy might be useful in the first line treatment of post-traumatic BA entrapment.


Assuntos
Fossa Craniana Posterior/lesões , Fossa Craniana Posterior/cirurgia , Procedimentos Neurocirúrgicos/métodos , Fratura da Base do Crânio/cirurgia , Insuficiência Vertebrobasilar/cirurgia , Idoso , Angiografia Digital , Anticoagulantes/uso terapêutico , Isquemia Encefálica/etiologia , Fossa Craniana Posterior/diagnóstico por imagem , Heparina/uso terapêutico , Humanos , Imagem por Ressonância Magnética , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Ponte/patologia , Fratura da Base do Crânio/complicações , Fratura da Base do Crânio/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/etiologia
11.
Radiol Clin North Am ; 57(3): 519-533, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30928075

RESUMO

There is renewed interest in ultrasound imaging of the vertebral artery due to the increasing use of stent placement for treating vertebral artery stenosis. Changes in vertebral artery waveforms are helpful in detecting pathologic processes involving the proximal and distal neurovascular circulation. We review the normal anatomy, scanning technique, normal gray scale, and color Doppler ultrasound appearance and differential diagnosis of spectral Doppler waveform changes in the extracranial vertebral artery. We review the ultrasound criteria for diagnosing vertebral artery stenosis, and the imaging appearance of non-atherosclerotic pathology that may affect the vertebral artery, including dissection, pseudoaneurysm, and arteriovenous fistula.


Assuntos
Ultrassonografia/métodos , Artéria Vertebral/diagnóstico por imagem , Insuficiência Vertebrobasilar/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Sensibilidade e Especificidade
12.
Medicine (Baltimore) ; 98(13): e14899, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30921187

RESUMO

This study aimed to compare the clinical efficacy of stenting compared with standardized medical treatment in patients with moderate to severe vertebral artery origin stenosis (VAOS).Patients diagnosed with moderate to severe VAOS and indicated to undergo vertebral artery stenting were enrolled. Patients were divided into stenting group and standardized medical treatment group. All patients underwent transcranial Doppler (TCD) before and after treatment. Incidence of new cerebral infarction, transient ischemic attack (TIA), improvement of clinical symptoms, and National Institutes of Health Stroke Scale (NIHSS) score were observed.A total of 98 patients were enrolled. Vertebral artery stenting implant was accepted by 43 patients. Two weeks after treatment, the NIHSS score in the stenting group decreased significantly compared to that in the standardized medical treatment group. The modified Rankin Scale (mRS) score in the stenting group at three months was significantly lower than that in the medical treatment group (P = .044). The extent of vascular stenosis in the stent group decreased significantly (76.5 ±â€Š10.0% vs. 13.7 ±â€Š5.9%, t = 35.878, P = .000). The adverse events occurred in 9 (16.4%) patients in the medical treatment group and 5 (11.6%) in the stenting group (P = .506). There was one case with new cerebral infarction in the stenting group, whereas the medical treatment group showed 1 case with TIA and three with new cerebral infarction during follow-up after 3 months. The peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI) of stenosis vertebral artery, and PSV of basilar artery were significantly higher in the stent group than those in the standardized medical group (P < .05).Stenting for VAOS, rather than standardized medical treatment, can effectively relieve vascular stenosis, alter vertebral-basilar artery hemodynamics, and improve neurological function, with low perioperative complications.


Assuntos
Hemodinâmica/fisiologia , Stents/efeitos adversos , Artéria Vertebral/diagnóstico por imagem , Insuficiência Vertebrobasilar/diagnóstico por imagem , Idoso , Constrição Patológica/patologia , Feminino , Seguimentos , Humanos , Incidência , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Prognóstico , Estudos Prospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Ultrassonografia Doppler Transcraniana/métodos , Artéria Vertebral/patologia , Insuficiência Vertebrobasilar/mortalidade , Insuficiência Vertebrobasilar/terapia
13.
J Stroke Cerebrovasc Dis ; 28(6): 1726-1731, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30898447

RESUMO

BACKGROUND AND PURPOSE: Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). We hypothesized that cardiac biomarkers (cardiac troponin and left atrial diameter [LAD]) would be associated with the presence of LVO. METHODS: Data were abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with CT angiography of the head and neck. The presence of LVO was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers (positive troponin [troponin ≥0.1 ng/mL] and LAD on transthoracic echocardiogram) and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF). RESULTS: We identified 1234 patients admitted with AIS; 886 patients (71.8%) had vascular imaging to detect LVO. Of those with imaging available, 374 patients (42.2%) had LVO and 207 patients (23.4%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age, sex and other risk factors (adjusted OR 1.69 [1.08-2.63], P = .022) and this association persisted after including AF in the model (adjusted OR 1.60 [1.02-2.53], P = 0.043). There was an association between LAD and LVO after adjusting for age, sex, and risk factors (adjusted OR per mm 1.03 [1.01-1.05], P = 0.013) but this association was not present when AF was added to the model (adjusted OR 1.01 [0.99-1.04], P = .346). Sensitivity analyses using thrombectomy as an outcome yielded similar findings. CONCLUSIONS: Cardiac biomarkers, particularly serum troponin levels, are associated with acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.


Assuntos
Isquemia Encefálica/etiologia , Estenose das Carótidas/etiologia , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Cardiopatias/complicações , Acidente Vascular Cerebral/etiologia , Troponina/sangue , Insuficiência Vertebrobasilar/etiologia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/terapia , Estenose das Carótidas/sangue , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Feminino , Cardiopatias/sangue , Cardiopatias/diagnóstico por imagem , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Trombectomia , Insuficiência Vertebrobasilar/sangue , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/terapia
14.
Clin Neuroradiol ; 29(3): 401-414, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30895349

RESUMO

Thrombectomy is a technique that has completely changed the management of acute stroke and current devices have shown that they can achieve upwards of 90% successful recanalization in selected cohorts. However, despite the effectiveness of these devices, there are a proportion of patients who still fail to achieve reperfusion of the affected vascular territory and an even larger portion of patients who have poor functional outcomes in spite of successful recanalization. There are no guidelines on how to treat these patients when such failures occur. In an effort to understand the underpinnings of how failed thrombectomy occurs, we extensively reviewed the current literature in clot properties, vascular access problems, stroke pathogenic mechanisms, embolic complications, failed procedures and pre-procedural imaging. A short summary of each of these contentious areas are provided and the current state of the art. Together these elements give a cohesive overview of the mechanisms of failed thrombectomy as well as the controversies facing the field. New techniques and devices can then be developed to minimize such factors during stroke thrombectomy.


Assuntos
Trombólise Mecânica/métodos , Acidente Vascular Cerebral/terapia , Trombose/patologia , Doença Aguda , Angiografia Digital , Angiografia Cerebral , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/patologia , Veias Cerebrais/diagnóstico por imagem , Veias Cerebrais/patologia , Eritrócitos , Fibrina/química , Humanos , Leucócitos , Trombólise Mecânica/instrumentação , Especificidade de Órgãos , Reperfusão , Acidente Vascular Cerebral/etiologia , Trombose/complicações , Falha de Tratamento , Grau de Desobstrução Vascular , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/terapia
15.
Pediatr Neurosurg ; 54(3): 196-200, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30889612

RESUMO

Developmental dolichoectasia of the intracranial vessels is a rare occurrence. The authors report 2 sibling pediatric patients who were born with 6p25.3 deletion, associated with carotid and vertebrobasilar dolichoectasia. MRI imaging of both children showed asymptomatic elongation and dilation of the vertebrobasilar system and "kissing" carotid arteries. A microarray analysis was also performed for both patients, which identified a 1.5-Mb deletion of 6p25.3 covering 15 genes including FOXC1, which has been implicated in defects in vascular morphogenesis.


Assuntos
Deleção Cromossômica , Cromossomos Humanos Par 6/genética , Deficiências do Desenvolvimento/genética , Insuficiência Vertebrobasilar/genética , Adolescente , Artéria Basilar/patologia , Artérias Carótidas/patologia , Criança , Feminino , Fatores de Transcrição Forkhead/genética , Humanos , Imagem por Ressonância Magnética , Masculino , Análise em Microsséries , Fenótipo , Insuficiência Vertebrobasilar/diagnóstico por imagem
16.
World Neurosurg ; 126: 146-150, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30858000

RESUMO

BACKGROUND: Cranial artery dolichoectasia is characterized by dilated, elongated, and tortuous cranial arteries. Dolichoectasia and dolichoectatic aneurysm-particularly of the internal carotid arteries (ICAs)-are rare but can lead to stroke. We report a case of suspected recurrent acute cerebral infarction and dolichoectatic aneurysm of the left ICA combined with right dolichoectatic aneurysm, vertebrobasilar dolichoectasia, and atrial fibrillation. CASE DESCRIPTION: An 80-year-old man experienced 3 days of recurrent aphasia episodes. He had a history of atrial fibrillation and hypertension. Neurologic findings indicated Wernicke aphasia. Magnetic resonance imaging showed acute cerebral infarction in the left temporal and parietal lobes. Magnetic resonance angiography and cerebral angiography showed dolichoectatic aneurysms in the C1-2 portion of the bilateral ICAs and vertebrobasilar dolichoectasia. Possible diagnoses included convulsion, cardioembolic infarction, atherothrombotic cerebral infarction, and acute ischemic stroke associated with the dolichoectatic aneurysm of the left ICA. Oral antiplatelet drugs, direct oral anticoagulants, and anticonvulsants were administered. Nine months after initial hospitalization, the patient had a recurrence of acute ischemic stroke and was rehospitalized. He was treated with a new direct oral anticoagulant, clopidogrel, statins, and ethyl icosapentate. At 2 years after initial hospitalization, he has had no recurrence of stroke, has a modified Rankin Scale score of 2, and is currently being followed as an outpatient. CONCLUSIONS: A direct oral anticoagulant (edoxaban) and clopidogrel were effective for suspected recurrent acute ischemic stroke associated with dolichoectatic aneurysm of the ICA combined with contralateral dolichoectatic aneurysm, vertebrobasilar dolichoectasia, and atrial fibrillation.


Assuntos
Aneurisma/complicações , Isquemia Encefálica/complicações , Doenças das Artérias Carótidas/complicações , Acidente Vascular Cerebral/complicações , Insuficiência Vertebrobasilar/complicações , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico por imagem , Aneurisma/tratamento farmacológico , Anticoagulantes/uso terapêutico , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/tratamento farmacológico , Artéria Carótida Interna/diagnóstico por imagem , Clopidogrel/uso terapêutico , Humanos , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Piridinas/uso terapêutico , Recidiva , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Tiazóis/uso terapêutico , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/tratamento farmacológico
17.
World Neurosurg ; 126: 552-559, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30926554

RESUMO

BACKGROUND: Vertebrobasilar insufficiency (VBI) is associated with high rates of morbidity and mortality, especially after failure of first-line medical and/or endovascular therapies. Although the optimal therapeutic strategy for refractory VBI remains unclear, surgical bypass represents a potentially life-saving treatment in this patient subset. METHODS: A multi-institution retrospective database review was performed to identify patients with symptomatic refractory VBI over a 4-year period (July 2014 to July 2018). Surgical treatments, as well as clinical and neurologic outcomes were recorded. RESULTS: Five patients were identified with refractory VBI (average age 55 ± 11.0 years). All 5 patients had clinically significant posterior circulation strokes on presentation. Three patients underwent superficial temporal artery-to-superior cerebellar artery bypass based on significant acute perfusion mismatches or progressive strokes despite maximal medical therapy; 1 surgical patient (33%) experienced punctate perioperative strokes and there were no significant bypass related complications. Functional outcomes in the 3 surgical patients were correlated with preoperative stroke burden. The remaining 2 patients experienced rapid neurologic declines after presentation that precluded bypass, and died shortly thereafter. CONCLUSIONS: Refractory VBI has high morbidity, with cerebral bypass representing a safe and potentially efficacious treatment for selected patients. Long-term post-bypass outcomes are dependent on the level of irreversible preoperative neurologic injuries.


Assuntos
Revascularização Cerebral , Insuficiência Vertebrobasilar/cirurgia , Adulto , Idoso , Anticoagulantes/uso terapêutico , Angiografia Cerebral , Revascularização Cerebral/métodos , Doença Crônica , Terapia Combinada , Bases de Dados Factuais , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neuroimagem , Transtornos Puerperais/tratamento farmacológico , Transtornos Puerperais/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/tratamento farmacológico
18.
PLoS One ; 14(2): e0212570, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30807597

RESUMO

OBJECTIVE: In vivo visualization of intracranial atherosclerotic plaque has been performed only with high-resolution magnetic resonance imaging (HRMR). We investigated whether atherosclerotic plaque of the basilar artery (BA) can be identified in conventional magnetic resonance imaging (MRI). METHODS: Patients with acute ischemic stroke who had BA stenosis ("symptomatic BAA") were retrospectively recruited using the prospective stroke registry. In the HRMR databank, subjects without BA stenosis were recruited and classified as those with silent plaque ("silent BAA") and without any plaque ("normal controls"). Outer diameter of the BA and T2 plaque sign (an eccentric or complete obscuration of normal flow-void) within the BA were assessed by two blinded raters using conventional T2 MRI. RESULTS: Seventy-five patients with symptomatic BAA, 40 with asymptomatic BAA, and 36 normal controls were included in the study. Maximal BA diameter was significantly larger in symptomatic BAA patients with <30%, 30-50%, 50-70%, and >70% stenosis (all p<0.01 in each subgroup) and silent BAA subjects (p = 0.018) than controls. T2 plaque signs were present in 46 (61.3%) patients with symptomatic BAA and 6 (14.6%) subjects with asymptomatic BAA, while none in normal controls (p <0.001 and 0.057, respectively). Detection rates were increased with an increase in stenosis degree (25.0% in <30% stenosis, 57.9% in 30-50% stenosis, 38.5% in 50-70% stenosis, 92.3% in 70-99% stenosis, and 100.0% in occlusion). CONCLUSIONS: Our data suggest that BA atherosclerosis can be detected by conventional MRI. When the use of HRMR is limited, conventional MR imaging may give additive information to clinicians.


Assuntos
Aterosclerose/diagnóstico por imagem , Artéria Basilar/diagnóstico por imagem , Imagem por Ressonância Magnética , Placa Aterosclerótica/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Insuficiência Vertebrobasilar/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos
19.
Cerebrovasc Dis ; 47(1-2): 48-56, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30783049

RESUMO

BACKGROUND AND PURPOSE: Renal dysfunction (RD) is overall associated with unfavorable functional outcome and higher risk of mortality after acute ischemic stroke. Associations between RD and outcome in patients with acute vertebrobasilar stroke treated with thrombectomy have not been evaluated so far. MATERIALS AND METHODS: Consecutive patients with vertebrobasilar stroke treated with mechanical thrombectomy between October 2010 and July 2017 at our center were analyzed. RD was defined as glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 at admission. Endpoints were (I) poor clinical outcome (modified Rankin Scale > 2) at 3 months, (II) 3-month mortality, and (III) intracerebral hemorrhage (ICH) after treatment. RESULTS: Overall, 106 patients were included. Median age was 73.0 years (interquartile range 62.0-80.0), and RD was present in 20.8%. Multivariate analysis revealed that RD was associated with a higher risk for any ICH (OR 3.54; 95% CI 1.09-11.49; p = 0.035). Stroke severity at onset predicted poor clinical outcome (OR 1.08; 95% CI 1.03-1.14; p = 0.003). Neither low GFR nor any ICH, but stroke severity (OR 1.08; 95% CI 1.03-1.14; p = 0.002) and poor recanalization results (OR 11.38; 95% CI 2.01-64.41; p = 0.006) were associated with a higher risk for mortality. CONCLUSIONS: Patients with RD and acute vertebrobasilar stroke should be thoroughly monitored to prevent ICH after thrombectomy. Our results support performing mechanical thrombectomy in acute stroke patients with large vessel occlusions of the posterior circulation, irrespective of their renal function.


Assuntos
Hemorragia Cerebral/etiologia , Taxa de Filtração Glomerular , Nefropatias/complicações , Rim/fisiopatologia , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Insuficiência Vertebrobasilar/cirurgia , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/diagnóstico por imagem , Bases de Dados Factuais , Feminino , Humanos , Nefropatias/diagnóstico , Nefropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Fatores de Tempo , Resultado do Tratamento , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/diagnóstico por imagem
20.
Cerebrovasc Dis ; 47(1-2): 40-47, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30763929

RESUMO

BACKGROUND: The natural history of vertebrobasilar artery (VBA) stenosis or occlusion remains understudied. METHODS: Patients with diagnosis of ischemic stroke or transient ischemic attack (TIA) who were noted to have VBA stenosis based on computed tomography or magnetic resonance imaging or catheter-based angiogram were selected from Taiwan Stroke Registry. Cox proportional hazards model was used to determine the hazards ratio (HR) of recurrent stroke and death within 1 year of index event in various groups based on severity of VBA stenosis (none to mild: 0-49%; moderate to severe: 50-99%: occlusion: 100%) after adjusting for differences in demographic and clinical characteristics between groups at baseline evaluation. RESULTS: None to mild or moderate to severe VBA stenosis was diagnosed in 6972 (66%) and 3,137 (29.8%) among 10,515 patients, respectively, and occlusion was identified in 406 (3.8%) patients. Comparing with patients who showed none to mild stenosis of VBA, there was a significantly higher risk of recurrent stroke (HR 1.21, 95% CI 1.01-1.45) among patients with moderate to severe VBA stenosis. There was a nonsignificantly higher risk of recurrent stroke (HR 1.49, 95% CI 0.99-2.22) and significantly higher risk of death (HR 2.21, 95% CI 1.72-2.83), among patients with VBA occlusion after adjustment of potential confounders. CONCLUSIONS: VBA stenosis or occlusion was relatively prevalent among patients with TIA or ischemic stroke and associated with higher risk of recurrent stroke and death in patients with ischemic stroke or TIA who had large artery atherosclerosis.


Assuntos
Acidente Vascular Cerebral/epidemiologia , Insuficiência Vertebrobasilar/epidemiologia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/mortalidade , Taiwan/epidemiologia , Fatores de Tempo , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/mortalidade
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