Anatomical Variations of Vertebrobasilar Artery are Closely Related to the Occurrence of Vertebral Artery Dissection—An MR Angiography Study

Goal: Intracranial arterial dissection is a major cause of ischemic stroke and subarachnoid hemorrhage in relatively young patients. We assessed the hypothesis that the tortuosity of the vertebrobasilar artery is associated with the occurrence of vertebral artery (VA) dissection, using MR angiography (MRA). Materials and Methods: This study enrolled 43 patients with VA dissection, and 63 age- and sex-matched healthy subjects were used as the controls. MRA was employed to evaluate the presence of dominant VA and the lateral shift of vertebrobasilar junction in both groups. The VA diameters were considered different when the difference was greater than .3 mm. These anatomical variations were divided into 3 types: Type 1 (vertebrobasilar junction within 2 mm from the midline), Type 2 (>2 mm-lateral shift of vertebrobasilar junction to the ipsilateral side of the dominant VA), and Type 3 (>2 mm-lateral shift of vertebrobasilar junction to the contralateral side of the dominant VA). Findings: The presence of dominant VA and the lateral shift of vertebrobasilar junction were more prevalent in patients with VA dissection than in the controls (OR: 3.46, P = .013, and OR: 4.51, P = .001, respectively). The lateral shift of vertebrobasilar junction was classified into Type 1 (n = 6), Type 2 (n = 13), and Type 3 (n = 17) among patients with VA dissection, while into Type 1 (n = 20), Type 2 (n = 8), and Type 3 (n = 7) among the controls. Type 3 predominance was observed in patients with VA dissection (P = .02). Conclusions: Anatomical variations of the vertebrobasilar artery may play an important role in the occurrence of VA dissection.     

Treatment of Carotid Artery Disease: Endarterectomy or Angioplasty?

The management of carotid stenosis has enjoyed renewed interest in the neurological community in recent years due to the advent of endovascular approaches. In concert, progress in medical treatment of these patients has rekindled the debate regarding the best management of carotid stenosis overall, both for symptomatic and asymptomatic disease. For symptomatic carotid stenosis, the major decision required is choosing the type of intervention best suited for individual patients: carotid endarterectomy versus carotid artery stenting. For patients with asymptomatic carotid stenosis, intensive medical management has evolved significantly over the past decade to decrease the risk of ischemic stroke to match surgical intervention under most circumstances. This review will examine the supporting evidence for each intervention, and discuss the recent advances in medical and endovascular therapy that provide the data for a new era in clinical decision making.     

Mechanical Thrombectomy of the Middle Cerebral Artery – Neither Segment nor Diameter Matter

ObjectivesThe aim of this study was to explore the role of the vessel diameter at the site of middle cerebral artery (MCA) occlusion in acute ischemic stroke patients who underwent mechanical thrombectomy (MT) regarding technical aspects, safety, and clinical outcomes.MethodsIn a retrospective analysis, cerebral artery diameters were measured using digital subtraction angiography in patients with isolated M1 or M2 occlusions undergoing MT. Associations between occluded vessel, occlusion diameter and outcomes were analyzed using logistic regression models adjusting for prespecified prognostic factors.Results168 patients with M1 occlusions and 98 patients with M2 occlusions who underwent MT were included. Mean vessel diameters at M1 and M2 occlusion sites differed significantly (2.15 +/− .36 1.55 +/− .38, P < .001). Vessel diameters at the occlusion site and occluded vessel segment did not predict good functional outcome (aOR 1.2 CI .28-5.26, P = .659; aOR .84 CI .35-2.03, P = .841) or mortality (aOR .21 CI .04-1.01, P = .215; aOR 1.36 CI .55-3.37, P = .676). No significant differences in successful recanalization, good functional outcome, mortality, procedural complications, and intracranial hemorrhages between M1 and M2 occlusions was observed.ConclusionsIn this study no significant effect of the MCA vessel diameter on successful recanalization, good functional outcome, or mortality of acute ischemic stroke patients treated with MT could be detected. However, these findings need to be confirmed in further studies.     

Is Management of Central Retinal Artery Occlusion the Next Frontier in Cerebrovascular Diseases?

Central retinal artery occlusion (CRAO) is a medical emergency that, if not treated, may result in irreversible loss of vision. It continues to be an important cause for acute painless loss of vision. Amaurosis fugax or “transient CRAO” has long been considered an equivalent of transient cerebral ischemic event. Animal models, in addition to data from retrospective and randomized clinical studies, provide valuable insights into the time interval for irreversible retinal ischemia. Subset analyses from 2 large studies of patients with CRAO show benefit from treatment with thrombolysis within 6 hours from symptoms onset. Significant workflow improvements after the intra-arterial therapy trials for acute ischemic stroke have occurred world over in last 5 years.Patients with CRAO are uniquely suited to receive maximum benefits from the changes in workflow for treatment of patient's acute ischemic stroke. Just as in clinical triage of acute ischemic stroke, correct and timely diagnosis of patients with CRAO may help in preventing visual loss. The approach to acute ocular ischemia should mimic that used for acute brain ischemia. Comprehensive stroke centers would be ideal triage centers for these patients in view of availability of multidisciplinary participation from vascular neurology, neuroendovascular surgery, and ophthalmology.Time is Retina!     

“Clip Anchor-Assisted Coil Embolization” for Endovascular Parent Artery Occlusion of Intracranial Traumatic Aneurysm

Traumatic cerebral aneurysms are histologically dissecting aneurysms or pseudoaneurysms, thus requiring parent artery occlusion for cure. Combination of endovascular parent artery occlusion and extracranial-intracranial bypass is considered optimal to obtain complete obliteration of the aneurysm and to avoid hemodynamic hypoperfusion. However, endovascular parent artery occlusion of the supraclinoid internal carotid artery (ICA) is at risk of ischemic complications due to distal coil protrusion to adjacent perforating arteries or distal embolism of the thrombi generated in the coil mass. A 20-year-old man presented with progressive left optic neuropathy following motor vehicle accident. Radiological examination revealed left supraclinoid ICA aneurysmal formation with dissecting change. We treated this traumatic supraclinoid ICA aneurysm by combination of endovascular parent artery occlusion and high-flow bypass in the hybrid operating room. An aneurysmal clip was applied on the ICA just distal to the aneurysm prior to coil embolization, and worked as a scaffold for subsequent filling coils and as a blockade for the distal emboli. This “clip anchor-assisted coil embolization” technique resulted in optimal parent artery occlusion for the traumatic aneurysm of the supraclinoid ICA with minimal risks of residual blood flow, intraoperative rupture, and thromboembolic complications.     

Hostility Now, Depression Later? Longitudinal Associations Among Emotional Risk Factors for Coronary Artery Disease

Background/Purpose

Given that emotional risk factors for coronary artery disease (CAD) tend to cluster within individuals, surprisingly little is known about how these negative emotions might influence one another over time. We examined the longitudinal associations among measures of depressive symptoms and hostility/anger in a cohort of 296 healthy, older adults.

Methods

Participants completed the Beck Depression Inventory-II (BDI-II), Cook–Medley Hostility (Ho) scale, and Anger-In and Anger-Out subscales of the State–Trait Anger Expression Inventory at baseline and 6-year follow-up. We conducted a series of path analyses to evaluate the directionality of the depression–hostility/anger relationship.

Results

Baseline Ho scale was a predictor of 6-year increases in BDI-II (β?=?0.15, p?=?0.004), Anger-In (β?=?0.14, p?=?0.002), and Anger-Out (β?=?0.11, p?=?0.01). In contrast, baseline BDI-II, Anger-In, and Anger-Out did not predict change in any of the emotional variables. Additional path analytic models revealed that the pattern of relationships was not altered after controlling for demographic, biomedical, and behavioral covariates; anxiety symptoms; social support; and subjective sleep quality.

Conclusions

The present results suggest that the cognitive aspects of hostility/anger may precede and independently predict future increases in depressive symptoms but not vice versa. Our findings lead us to speculate that (a) hostility may exert part of its cardiotoxic influence by acting to precipitate and/or maintain symptoms of depression and that (b) the potency of depression interventions designed to improve cardiovascular outcomes might be enhanced by incorporating treatments addressing hostility.     

Multimodal Neuroprotection Induced by PACAP38 in Oxygen–Glucose Deprivation and Middle Cerebral Artery Occlusion Stroke Models

Pituitary adenylate cyclase activating peptide (PACAP), a potent neuropeptide which crosses the blood-brain barrier, is known to provide neuroprotection in rat stroke models of middle cerebral artery occlusion (MCAO) by mechanism(s) which deserve clarification. We confirmed that following i.v. injection of 30?ng/kg of PACAP38 in rats exposed to 2?h of MCAO focal cerebral ischemia and 48?h reoxygenation, 50?% neuroprotection was measured by reduced caspase-3 activity and volume of cerebral infarction. Similar neuroprotective effects were measured upon PACAP38 treatment of oxygen-glucose deprivation and reoxygenation of brain cortical neurons. The neuroprotection was temporally associated with increased expression of brain-derived neurotrophic factor, phosphorylation of its receptor-tropomyosin-related kinase receptor type B (trkB), activation of phosphoinositide 3-kinase and Akt, and reduction of extracellular signal-regulated kinases 1/2 phosphorylation. PACAP38 increased expression of neuronal markers beta-tubulin III, microtubule-associated protein-2, and growth-associated protein-43. PACAP38 induced stimulation of Rac and suppression of Rho GTPase activities. PACAP38 downregulated the nerve growth factor receptor (p75(NTR)) and associated Nogo-(Neurite outgrowth-A) receptor. Collectively, these in vitro and in vivo results propose that PACAP exhibits neuroprotective effects in cerebral ischemia by three mechanisms: a direct one, mediated by PACAP receptors, and two indirect, induced by neurotrophin release, activation of the trkB receptors and attenuation of neuronal growth inhibitory signaling molecules p75(NTR) and Nogo receptor.     

Could A1 Aplasia or Hypoplasia Affect the Morphology and Rupture Risk of Anterior Communicating Artery Aneurysm?

ObjectiveAnterior communicating artery (Acom) aneurysm is one of the most common intracranial aneurysms, constituting approximately 30–35% of all aneurysm formation in the brain. Anatomically, the H-complex (the anatomic morphology of both A1 to A2 segments) is thought to affects the nature of the Acom aneurysm due to its close relationship with the hemodynamics of the vessel. Therefore, we investigated the relative risk factors of aneurysmal rupture, especially focusing on H-complex morphology of the Acom. MethodsFrom January 2016 to December 2020, a total of 209 patients who underwent surgery, including clipping and coiling for Acom aneurysm in our institution were reviewed. There were 102 cases of ruptured aneurysm and 107 cases of unruptured aneurysm. The baseline morphology of aneurysms was investigated and the relationship between the H-complex and the clinical characteristics of patients with Acom aneurysms was assessed. ResultsOf the 209 patients, 109 patients (52.1%) had symmetrical A1, 79 patients (37.8%) had unilateral hypoplastic A1, and 21 patients (10.0%) had aplastic A1. The hypoplastic A1 group and the aplastic A1 group were grouped together as unilateral dominancy of A1, and were compared with the symmetrical A1 group. There was no significant difference in demographic characteristics and radiological findings of Acom aneurysms between two groups. However, when dichotomizing the patients into ruptured cases and unruptured cases, unilateral dominance of the A1 segment was associated with aneurysmal rupture with statistical significance (p=0.011). ConclusionThese results suggest that the unilateral dominance of the A1 segment does not have a significant effect on the morphology of Acom aneurysms, but contributes to aneurysmal rupture. Thus, we can better understand the effects of hemodynamics on Acom aneurysm.     

Who Should Be Screened for Asymptomatic Carotid Artery Stenosis? Experience From the Western New York Stroke Screening Program

OBJECTIVE: Identification of significant asymptomatic carotid artery stenosis (ACAS) is important because of the stroke-risk reduction observed with carotid endarterectomy. The authors developed and validated a simple scoring system based on routinely available information to identify persons at high risk for ACAS using data collected during a community health screening program at various sites in western New York. A total of 1331 unselected volunteers without previous stroke, transient ischemic attack, or carotid artery surgery were evaluated by personal interview and duplex ultrasound. The main outcome measure was carotid artery stenosis > 60% by duplex ultrasound. In the derivation set (n = 887), 4 variables were significantly associated with ACAS > 60%: age > 65 years (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 2.6-6.7), current smoking (OR = 2.0, 95% CI = 1.2-3.5), coronary artery disease (OR = 2.4, 95% CI = 1.5-3.9), and hypercholesterolemia (OR = 1.9, 95% CI = 1.2-2.9). Three risk groups (low, intermediate, and high) were defined on the basis of total risk score assigned on the basis of the strength of association. The scheme effectively stratified the validation set (n = 444); the likelihood ratio and posttest probability for ACAS in the high-risk group were 3.0 and 35%, respectively, and in the intermediate and low-risk groups were 1.4 and 20% and 0.4 and 7%, respectively. Routinely available information can be used to identify persons in the community at high risk for ACAS. Doppler ultrasound screening in this subgroup may prove to be cost-effective and have an effect on stroke-free survival.     

Is Computerized Tomography Angiographic Surveillance Valuable for Prevention of Tracheoinnominate Artery Fistula,a Life-Threatening Complication after Tracheostomy?

Objective

The aim of this study was to evaluate the utility of volume-rendered helical computerized tomography (CT) angiography focusing tracheostomy tube and innominate artery for prevention of tracheoinnominate artery fistula.

Methods

The authors retrospectively analyzed 22 patients with tracheostomy who had checked CT angiography. To evaluate the relationship between tracheostomy tube and innominate artery, we divided into three categories. First, proximal tube position based on cervical vertebra, named "tracheostomy tube departure level (TTDL)". Second, distal tube position and course of innominate artery, named "tracheostomy tube-innominate artery configuration (TTIC)". Third, the gap between the tube and innominate artery, named "tracheostomy tube to innominate artery gap (TTIG)". The TTDL/TTIC and TTIG are based on 3-dimensional (3D) reconstruction around tracheostomy and enhanced axial slices of upper chest, respectively.

Results

First, mean TTDL was 6.8±0.6. Five cases (23%) were lower than C7 vertebra. Second, TTIC were remote to innominate artery (2 cases; 9.1%), matched with it (14 cases; 63.6%) or crossed it (6 cases; 27.3%). Only 9% of cases were definitely free from innominate artery injury. Third, average TTIG was 4.3±4.6 mm. Surprisingly, in 6 cases (27.3%), innominate artery, trachea wall and tracheostomy tube were tightly attached all together, thus have much higher probability of erosion.

Conclusion

If low TTDL, match or crossing type TTIC with reverse-L shaped innominate artery, small trachea and thin TTIG are accompanied all together, we may seriously consider early plugging and tube removal.     

Progression of Coronary Artery Calcification in Black and White Women: Do the Stresses and Rewards of Multiple Roles Matter?

Background  

Black women experience higher rates of cardiovascular disease (CVD) than white women, though evidence for racial differences in subclinical CVD is mixed. Few studies have examined multiple roles (number, perceived stress, and/or reward) in relation to subclinical CVD, or whether those effects differ by race.     

Learning Vector Quantization Neural Networks Improve Accuracy of Transcranial Color-coded Duplex Sonography in Detection of Middle Cerebral Artery Spasm—Preliminary Report

To determine the performance of an artificial neural network in transcranial color-coded duplex sonography (TCCS) diagnosis of middle cerebral artery (MCA) spasm. TCCS was prospectively acquired within 2 h prior to routine cerebral angiography in 100 consecutive patients (54M:46F, median age 50 years). Angiographic MCA vasospasm was classified as mild (<25% of vessel caliber reduction), moderate (25–50%), or severe (>50%). A Learning Vector Quantization neural network classified MCA spasm based on TCCS peak-systolic, mean, and end-diastolic velocity data. During a four-class discrimination task, accurate classification by the network ranged from 64.9% to 72.3%, depending on the number of neurons in the Kohonen layer. Accurate classification of vasospasm ranged from 79.6% to 87.6%, with an accuracy of 84.7% to 92.1% for the detection of moderate-to-severe vasospasm. An artificial neural network may increase the accuracy of TCCS in diagnosis of MCA spasm.