Bilateral intracranial vertebral artery disease in the New England Medical Center, Posterior Circulation Registry.

BACKGROUND: Previous studies of patients with bilateral intracranial vertebral artery (ICVA) disease were selective and retrospective. METHODS: We studied risk factors, vascular lesions, symptoms, signs, and outcomes in patients with bilateral ICVA disease among 430 patients in the New England Medical Center Posterior Circulation Registry. RESULTS: Forty-two patients had bilateral ICVA occlusive disease (18 had bilateral stenosis; 16, unilateral occlusion and contralateral stenosis; and 8, bilateral occlusion). The most common risk factors were hypertension (32/42 [76%]) and hyperlipidemia (22/42 [52%]). Sixteen patients (38%) had transient ischemic attacks (TIAs) only; 18 (43%), TIAs before stroke. Occlusive vascular disease also involved the basilar artery in 29 patients (69%), the extracranial vertebral arteries in 18 (43%), and the internal carotid arteries in 11 (26%). Only 6 patients had no other major vascular lesion. Cerebellar symptoms were common. Among 30 patients with infarction, 21 (70%) had proximal intracranial territory involvement, and 15 (50%) had distal territory involvement. The location of occlusive lesions in relation to posterior inferior cerebellar artery origins did not significantly influence prognosis. During follow-up, 31 patients had no symptoms or slight disability, 2 had progression, and 7 died. Among 7 patients with poor outcome, 6 also had basilar artery stenosis or occlusion and 5 had proximal and distal intracranial territory infarcts. CONCLUSIONS: Most patients with bilateral ICVA occlusive disease have hypertension, other major occlusive lesions, and TIAs before stroke. Short- and long-term outcomes are usually favorable, but patients with bilateral ICVA and basilar artery-occlusive lesions often have poor outcomes.     

Basilar artery stenosis: middle and distal segments

We report the clinical features and prognosis in nine patients with angiographically documented basilar artery stenosis of the middle and distal segments. Six patients had transient ischemic attacks (TIAs), and in two this was their only clinical manifestation. The TIAs in four patients included two or more of the following symptoms: dizziness, diplopia, perioral numbness, dysphagia, weakness, or loss of consciousness. Two other patients had isolated symptoms of transient dizziness and unilateral weakness. Seven patients had posterior circulation strokes, preceded by TIAs in four. Basilar artery occlusive disease can affect any segment of the artery. The short-term prognosis of middle and distal basilar artery stenosis was good especially when patients were treated with warfarin or platelet antiaggregants.     

The intracranial vertebral artery: a neglected species. The Johann jacob wepfer award 2012

Among posterior circulation arteries, the intracranial vertebral artery (ICVA) has been given the least attention, especially concerning treatment of occlusive lesions. Early clinicopathological studies showed that the ICVA was often occluded in patients with lateral medullary and posterior inferior cerebellar infarcts. Severe stenosis or occlusion of the ICVA was the most common arterial lesion among the 408 patients in the New England Medical Center Posterior Circulation Registry (NEMC-PCR). In this registry, the distal portion of the artery was most often involved, sometimes with spread into the basilar artery. ICVA occlusive lesions were often bilateral and very often accompanied by basilar and cervical vertebral artery occlusive lesions. Patients with bilateral ICVA occlusions often had attacks of dizziness, blurred vision, and ataxia during months and years but rarely later developed disabling infarction. Most posterior circulation infarcts in patients with ICVA occlusive lesions were located in the middle and distal posterior circulation territories and were rostral to the medulla and inferior cerebellum. Although diagnostic techniques now image the ICVA and its lesions well, the optimal treatment of patients with various ICVA occlusive lesions has very rarely been analyzed or reported. The therapeutics of patients with ICVA disease is uncharted territory and begs for attention and clarification.     

双侧椎动脉/基底动脉重度狭窄或闭塞的急性后循环梗死患者临床特点及预后分析

目的总结分析双侧椎动脉/基底动脉重度狭窄或闭塞的急性后循环梗死患者的临床特点和预后。方法收集急性后循环梗死且伴有双侧椎动脉/基底动脉重度狭窄或闭塞的住院患者资料,分析其血管危险因素、起始症状、治疗及病情演变情况,并随访90 d预后,以mRS2分定义为预后不良。结果共纳入28例患者,最常见的起始症状为孤立性头晕或眩晕(57.1%)。53.6%的患者出现病情加重,加重≥2次9例(32.1%),预后不良15例(53.6%)。预后不良组高血压3级、病情加重、加重≥2次比例明显高于预后良好组(P0.05)。病情加重≥2次组高血压3级、高脂血症、孤立性头晕或眩晕起病、预后不良和死亡比例明显高于加重2次组(P0.05)。基底动脉不显影组死亡率(75%)明显高于显影组(4.2%)(P0.05)。结论双侧椎动脉/基底动脉重度狭窄或闭塞的急性后循环梗死患者多以孤立性头晕或眩晕起病;孤立性头晕或眩晕起病和高血压3级患者病情容易加重;病情反复加重患者预后不良比例高,死亡率高;基底动脉不显影患者死亡率高。     

New England Medical Center Posterior Circulation Stroke Registry II. Vascular Lesions

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, the extracranial (ECVA) and intracranial vertebral arteries (ICVA) were the commonest sites of severe occlusive disease followed by the basilar artery (BA). Severe occlusive lesions were found in >1 large artery in 148 patients; 134 had unilateral or bilateral severe disease at one arterial location. Single arterial site occlusive disease occurred most often in the ECVA (52 patients, 15 bilateral) followed by the ICVA (40 patients, 12 bilateral) and the BA (46 patients). Involvement of the ICVAs and the BA was very common and some patients also had ECVA lesions. Hypertension, smoking, and coronary and peripheral vascular disease were most prevalent in patients with extracranial disease while diabetes and hyperlipidemia were more common when occlusive lesions were only intracranial. Intra-arterial embolism was the most common mechanism of brain infarction in patients with ECVA and ICVA occlusive disease. ICVA occlusive lesions infrequently caused infarction limited to the proximal territory (medulla and posterior inferior cerebellum). BA lesions most often caused infarcts limited to the middle posterior circulation territory (pons and anterior inferior cerebellum). Posterior cerebral artery occlusive lesions were predominantly embolic. Penetrating artery disease caused mostly pontine and thalamic infarcts. Prognosis was poorest in patients with BA disease. The best prognosis surprisingly was in patients who had multiple arterial occlusive lesions; they often had position-sensitive transient ischemic attacks during months or years.     

New England Medical Center Posterior Circulation registry

Among 407 New England Medical Center Posterior Circulation registry patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs then strokes, and 16% had only TIAs. Embolism was the commonest stroke mechanism (40% of patients including 24% cardiac origin, 14% intraarterial, 2% cardiac and arterial sources). In 32% large artery occlusive lesions caused hemodynamic brain ischemia. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes); the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Severe occlusive lesions (>50% stenosis) involved more than one large artery in 148 patients; 134 had one artery site involved unilaterally or bilaterally. The commonest occlusive sites were: extracranial vertebral artery (52 patients, 15 bilateral) intracranial vertebral artery (40 patients, 12 bilateral), basilar artery (46 patients). Intraarterial embolism was the commonest mechanism of brain infarction in patients with vertebral artery occlusive disease. Thirty-day mortality was 3.6%. Embolic mechanism, distal territory location, and basilar artery occlusive disease carried the poorest prognosis. The best outcome was in patients who had multiple arterial occlusive sites; they had position-sensitive TIAs during months to years.     

Clinical features of proven basilar artery occlusion

Our study describes the early symptoms and signs of 85 patients with either basilar artery occlusion or bilateral distal vertebral artery occlusion documented by selective angiography. The most common prodromal symptoms were vertigo, nausea, and headache, which occurred during the 2 weeks before the stroke. Angiographic findings of 49 patients were classified into proximal, middle, and distal basilar artery occlusions. Twenty-two of these patients had additional vertebral artery lesions. A fourth group was composed of 36 patients with bilateral distal vertebral artery occlusion without opacification of the basilar artery through a vertebral artery injection. Onset was sudden in 20 patients; sudden, but preceded by prodromal symptoms in 11 patients; and progressive in 54 patients. Patients with progressive strokes often had bilateral vertebral artery occlusions. Most patients with acute onset had occlusion of the middle and distal basilar artery. An embolic origin of basilar artery occlusion from an arteriosclerotic vertebral artery lesion was assumed to be an important mechanism. An embolus reaching the basilar artery may not necessarily reach the top of the artery, but may also become lodged more proximally.     

Stroke in patients with fusiform vertebrobasilar aneurysms

We studied seven patients with brainstem infarction and large fusiform vertebrobasilar (VB) aneurysms to clarify the clinical, radiologic, and pathologic features. All presented with pontine infarcts; one also had a cerebellar infarct. VB TIAs preceded brainstem infarction in four patients. Angiography and CT documented VB fusiform aneurysmal dilatation. Four had intraluminal thrombi and one had severe basilar artery stenosis. Two distinct clinical pictures emerged: unilateral pontine infarcts with favorable outcome, presumably related to obstruction of a pontine penetrating artery at its origin from the posterior wall of the aneurysmal basilar artery, and major fatal bilateral pontine infarcts from basilar artery occlusion. Two patients came to autopsy. One had thrombus in the dilated basilar artery and a posterior cerebral artery branch embolus with hemorrhagic occipital infarction; the other had basilar artery thrombus with aneurysmal rupture and subarachnoid hemorrhage. Fusiform VB aneurysms caused brainstem stroke by intraluminal thrombus, local embolism, atherostenosis, and obstruction of paramedian penetrating arteries. Subarachnoid hemorrhage is an uncommon complication.     

Stenosis and occlusion of the subclavian artery: ultrasonographic and clinical findings

Summary Continuous-wave (CW) Doppler sonography has proved to be a reliable tool both to detect subclavian stenosis or occulusion and to detect reversal of blood flow in the vertebral artery. This method is entirely atraumatic and in contrast to angiography allows investigation of asymptomatic patients and provides more representative data for epidemiological studies. The incidence of subclavian stenosis or occlusion was 1.15% among the 23,500 patients examined in our department between 1978 and 1985. Of the 272 patients with unilateral or bilateral subclavian stenosis or occlusion, 54% were asymptomatic with no subjective complaints and were normal upon neurological examination; 29% reported vertebrobasilar transient ischaemic attacks (TIAs), with or without concomitant TIAs or infarction in the vascular territory of the carotid arteries; and 17% complained of symptoms exclusively referring to the region of carotid blood supply. Reversal of blood flow in the ipsilateral vertebral artery was detected in 152 patients (56%). The incidence of neurological symptoms within this group was double that found in patients without steal. None of the patients suffered from permanent vertebrobasilar damage. In most cases, subclavian artery disease was due to atherosclerosis. For 13 patients an inflammatory, iatrogenic, traumatic, or congenital aetiology could be assumed. The marked preponderance of left-sided subclavian stenosis or occlusion, reported by others, could be confirmed among our patients, but was less pronounced for tight stenoses than for occlusions. Mild-to-moderate subclavian stenoses were about equally distributed on each side.     

加强对后循环缺血性卒中/短暂性脑缺血发作的认识

后循环缺血性卒中（posterior circulation stroke,PCS）/短暂性脑缺血发作（transient ischemic attack,TIA）占全部卒中及TIA的1/5,其临床表现按血管分布可呈现不同的症状,以头晕最常 见。50%以上椎-基底动脉梗死患者在几天或几周前会出现TIA症状,这些先兆症状可辅助早期识别 PCS。PCS的复发率高于前循环,尤其是伴椎-基底动脉狭窄的患者,可通过完善计算机断层扫描血管 成像（computed tomography angiography,CTA）、磁共振血管成像（magnetic resonance angiography,MRA） 等辅助检查明确血管狭窄程度。另外,对侧支循环建立充分的后循环重度狭窄或闭塞,其神经功能 缺损程度较轻,且预后更好。     

Acute bilateral cerebellar infarcts in the territory of posterior inferior cerebellar artery

The authors report 12 patients with acute bilateral cerebellar infarcts in posterior inferior cerebellar artery (PICA) territory. They found three topographic patterns: A) bilateral medial PICA in six patients; B) unilateral whole + contralateral medial PICA in four; and C) bilateral small multiple in two. Nine patients in Groups A and B had unilateral PICA or vertebral artery disease, and both patients in Group C had bilateral vertebral artery disease. These findings support that unilateral supply to both medial PICA territories may be the most relevant pathogenesis of this syndrome.     

Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: Experience of a single center and review of literature

Objective

The optimal treatment of chronic symptomatic total occlusion of the intracranial vertebral artery (ICVA) remains undefined. We report a single-center experience of endovascular recanalization for patients with chronic symptomatic ICVA occlusion who were refractory to medical therapy.

Acute bilateral cerebellar infarction in the territory of the medial branches of posterior inferior cerebellar arteries

The most frequent type of cerebellar infarcts involved the posterior inferior cerebellar artery (PICA) and superior cerebellar artery territories but bilateral involvement of lateral or medial branches of PICA is extremely rare. In this report, we present a 55-year-old male who admitted to hospital with vomiting, nausea and dizziness. On examination left-sided hemiparesia and ataxic gait were detected. Infarct on bilateral medial branch of PICA artery territories was found out with cranial magnetic resonance imaging (MRI) technique and 99% stenosis of the left vertebral artery was found out with digital subtraction arteriography. The patient was put on heparin treatment. After 3 weeks, his complaints and symptoms had disappeared except for mild gait ataxia.     

119例小脑梗死的临床分析

目的探讨小脑梗死的中国缺血性脑卒中分型诊断(CISS)、受累血管区域、合并小脑外梗死病灶以及临床表现。方法回顾性分析自2012年1月至2015年12月119例急性小脑梗死住院患者的头颅MRI影像、病因学检查以及临床表现等资料。结果 119例小脑梗死患者中,单侧小脑梗死78例(UCI组),双侧小脑梗死41例(BCI组)。两组的CISS分型无明显差异。UCI组以小脑后下动脉区梗死发生率最高(35.9%),与BCI组比较,差异有显著统计学意义(P0.01);BCI组中小脑后下动脉+小脑上动脉区梗死发生率最高(39.0%),但两组间比较差异无显著性;其余区域的梗死发生率在两组中差异无显著性。63/119例(52.9%)同时合并小脑外梗死灶。BCI组合并小脑外后循环梗死的发生率(53.7%)较单侧UCI组高(P0.05),而UCI组合并前循环梗死较BCI组更多(P0.05)。主要症状、体征包括:头晕/眩晕、眼球震颤、眼倾斜反应、听觉减退、小脑性构音障碍、共济失调,浅感觉障碍、锥体束征以及意识障碍等。意识障碍在BCI组的发生率高于UCI组(P0.01),其余各项两组间比较差异无显著性。结论小脑梗死的主要病因为大动脉粥样硬化;小脑后下动脉区梗死在UCI中最常见,BCI常合并小脑外的后循环供血区梗死;UCI和BCI的受累小脑动脉以及合并小脑外梗死的区域有一定差异,提示两者病因机制存在不同;意识障碍等严重神经功能缺损表现在BCI更为常见。     

The role of vertebral and internal carotid artery disease in the pathogenesis of vertebrobasilar transient ischemic attacks

Summary Color-coded duplex sonography has improved the evaluation of the hemodynamics of the vertebral arteries (VA). A reliable differentiation between a normal vessel, hypoplasia, stenosis and occlusion of VA can now be made. We studied two groups of patients in a prospective study with isolated carotid artery disease (n=48), and with a combination of carotid and vertebral artery disease (n=14), to determine the role of VA in the pathogenesis of transient ischemic attacks (TIAs) in the vertebrobasilar system. Apart from the existing arteriosclerotic changes of the internal carotid arteries, the condition of the VA was of importance for the occurrence of TIAs in the vertebrobasilar territory. We found that 8% of the patients with isolated hemodynamically relevant stenosis or occlusion of one or both internal carotid arteries had a TIA in the vertebrobasilar territory. Patients with combined carotid and vertebral artery disease had an increase of TIAs in the same region in 71%. The high rate of TIAs in this group might be attributed to the combined effect of carotid and vertebral artery disease, as a third group (n=30) with isolated vertebral artery disease showed TIAs in only 13%.     

椎动脉形态学异常对后循环短暂性脑缺血发作症状持续时间的影响

目的 探讨椎动脉形态学异常对后循环TIA症状持续时间的影响。 方法 回顾性分析2015年10月-2018年3月在中国科学院大学重庆仁济医院神经内科完成头颈部DSA 或CTA的后循环TIA住院患者临床资料,根据症状持续时间分为<10 min组、10～59 min组和≥60 mi n组, 比较椎动脉形态异常各亚型在3组间的差异。通过多因素Logistic回归分析明确椎动脉形态异常与后 循环TIA症状持续时间之间的关系。 结果 共纳入237例患者,其中症状持续时间<10 min组109例（45.99%）、10～59 min组71例（29.96%） 和≥60 min组57例（24.05%）。一般临床资料的比较显示,性别、椎动脉和基底动脉狭窄率≥50% 在3组间差异具有统计学意义（P＜0.05）。椎动脉形态异常中,动脉粥样硬化性椎动脉狭窄（狭窄 率1%～99%）在3组间的差异具有统计学意义（P =0.004）,而一侧迂曲、双侧迂曲、一侧优势、一 侧优势合并迂曲和起源异常在3组间差异均无统计学意义;多因素Logi sti c回归分析显示椎动脉 狭窄（OR 2.500,95%CI 1.381～4.525,P =0.002）、基底动脉狭窄率≥50%（OR 12.066,95%CI 1.446～100.668,P =0.021）是TI A症状持续时间延长的独立影响因素。 结论 椎动脉狭窄和基底动脉狭窄率≥50%是影响后循环TIA症状持续时间延长的独立影响因素。     

Bilateral occlusion of the trunk of the middle cerebral artery. Results of an international randomized trial. The EC/IC Bypass Study Group

Bilateral occlusion of the middle cerebral artery (MCA) trunk theoretically should be a very severe condition, but its actual prognosis has never been studied. Nine of 1,377 patients (7 Asians, 1 Black, 1 Caucasian) from the Cooperative Study of Extracranial/Intracranial Arterial Anastomosis were found to have atherosclerotic bilateral occlusion of the middle cerebral artery (MCA) trunk before entering the trial. Three presented with a stroke followed by a contralateral stroke, two experienced a unilateral stroke, two had a unilateral stroke preceded by ipsilateral TIAs, one had a unilateral stroke preceded by TIAs on both sides and one experienced isolated unilateral TIAs. Retrograde filling to the distal MCA was universally present. During follow-up (mean: 45 months), only one (non-operated) patient had further cerebrovascular events, and ultimately a fatal stroke. One additional patient died of sepsis and one had a silent myocardial infarct. All survivors resumed their previous activities. This study shows that in bilateral MCA trunk occlusion, the long-term prognosis is reasonable in the patients who do not present with a devastating stroke.     

Heralding manifestations of basilar artery occlusion with lethal or severe stroke

BACKGROUND: Basilar artery occlusion usually causes severe disability or death. Until the recent developments in local intra-arterial or systemic intravenous fibrinolysis, interest in early diagnosis was low because there was no satisfactory treatment. Thus there is little information about the initial phase of the disease. OBJECTIVE: To report on the early clinical features and patterns of evolution of severe symptomatic basilar artery occlusion. METHODS: 24 patients with established basilar artery occlusion (confirmed by angiography or at necropsy) were reviewed retrospectively, focusing on the early clinical aspects and time course of the disease. RESULTS: The most common initial symptoms were motor deficits (16/24, including facial palsies), articulatory speech difficulties (15/24), vertigo, nausea or vomiting (13/24), and headaches (10/24). The most frequent objective initial findings were motor deficits (22/24), facial palsies (19/24), eye movement abnormalities (15/24), lower cranial nerve deficits (15/24), altered level of consciousness (12/24), and bilateral extensor plantar responses (9/24). Onset of the disease was gradual in nearly all patients and in half the warning signs were present for up to two months before the final stage. Headaches and visual disturbances were early signs, while speech difficulties and motor deficits were late signs. Once permanent neurological deficits were present, the final illness was reached within six hours in 41%, between six and 24 hours in 32%, and in two to three days in 27%. CONCLUSIONS: All the patients reviewed presented some symptoms and signs pointing to brain stem involvement. Only 8% (2/24) had an acute course with no adequate warning signs.     

数字减影血管造影对缺血性脑血管病诊断及治疗的意义

目的:探讨数字减影血管造影检查(DSA)对缺血性脑血管病血管病变诊断的意义。方法:选取有脑缺血症状的经TCD检查发现血管狭窄的21例病人,行DSA检查。结果:颈内动脉系统TIA患者3例,DSA证实为大脑中动脉狭窄2例,烟雾病1例,椎基底动脉供血不足8例中双侧椎动脉发育不全1例,一侧或双侧椎动脉狭窄5例,锁骨下动脉盗血2例。8例脑梗塞患者中已经出现一侧颈内动脉闭塞的有两例,但均已出现侧枝循环的建立,另6例均为颈内动脉或大脑中动脉的狭窄,2例脑干梗塞患者均有椎动脉的狭窄。结论:数字减影血管造影是评价头颈部血管狭窄、闭塞和选择治疗方案的金标准,它对缺血性脑血管病的进一步治疗起着重要的作用。     

Dissection of the intracranial vertebral artery

We describe four patients and review prior reports to clarify the clinical, radiographic, and pathologic findings of intracranial vertebral artery (VA) dissection. A 43-year-old man and a 33-year-old woman had chronic bilateral VA dissecting aneurysms. The man had multiple episodes of subarachnoid hemorrhage (SAH) and necropsy showed multiple dissections and defects in the internal elastica. The woman had many brainstem TIAs and strokes during 3 years. Two other patients had SAH and unilateral dissections. Intracranial VA dissection causes four overlapping syndromes: (1) brainstem infarcts are usually due to subintimal dissection extending into the basilar artery, affect younger patients, and often are single fatal events; (2) SAH is due to subadventitial or transmural dissection; (3) aneurysms cause mass effect on the brainstem and lower cranial nerves; and (4) chronic dissections due to connective tissue defects cause extensive bilateral aneurysms and repeated TIAs, small strokes, and SAH.