Dolichoectatic aneurysms of the vertebrobasilar system: clinical and radiographic factors that predict poor outcomes

Xu, David S.; Levitt, Michael R.; Kalani, M. Yashar S.; Rangel-Castilla, Leonardo; Mulholland, Celene B; Abecassis, Isaac J.; Morton, Ryan P.; Nerva, John D.; Siddiqui, Adnan H.; Levy, Elad I.; Spetzler, Robert F.; Albuquerque, Felipe C.; McDougall, Cameron G.

doi:10.3171/2016.10.jns161041

Cited by 20 publications

(33 citation statements)

References 16 publications

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“…Pearson correlations and multivariable linear regression were used to look for associations between MFV and composite Z-score, adjusting for age, education, and depression, entering variables stepwise with p ≤ 0.10 (SPSS v. 22). The Davies test [17] was used to determine whether there was a single breakpoint for a non-zero difference in slope of a segmented relationship between the main variables of interest: MFV and composite Z-score.…”

Section: Discussionmentioning

confidence: 99%

“…A second example is the effect of dolichoectasia in the vertebrobasilar system. Remarkably long periods of asymptomatic status may exist until a threshold of the mass effect on the brainstem is reached, at which point patients' functional status begins to decline [22]. Finally, in addition to largevessel contributions to flow, cognitive dysfunction correlates with reduced brain blood flow in small-vessel disease [23,24].…”

Section: Discussion/conclusionmentioning

confidence: 99%

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Cognitive Impairment Correlates Linearly with Mean Flow Velocity by Transcranial Doppler below a Definable Threshold

Marshall

Pavol

Cheung

et al. 2020

Cerebrovasc Dis Extra

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Introduction: Low cerebral blood flow can affect cognition in patients with high-grade asymptomatic internal carotid artery stenosis. Current clinical algorithms use stroke risk to determine which patients should undergo revascularization without considering cognitive decline. Although correlations between low-flow and cognitive impairment have been reported, it is not known whether a threshold exists below which such a correlation expresses itself. Such information would be critical in treatment decisions about whether to intervene in patients with high-grade carotid artery stenosis who are at risk for cognitive decline. Objective: To determine how reduced blood flow correlates with lower cognitive scores. Methods: Patients with ≥80% unilateral internal carotid artery stenosis with no history of stroke were recruited from inpatient and outpatient practices at a single, large, comprehensive stroke center. Patients underwent bilateral insonation of middle cerebral arteries with standard 2-Hz probes over the temporal windows with transcranial Doppler. Cognitive assessments were performed by an experienced neuropsychologist using a cognitive battery comprising 14 standardized tests with normative samples grouped by age. Z-scores were generated for each test and averaged to obtain a composite Z-score for each patient. Multivariable linear regression examined associations between mean flow velocity (MFV) and composite Z-score, adjusting for age, education, and depression. The Davies test was used to determine if there was a breakpoint for a non-zero difference in slope of a segmented relationship over the range of composite Z-score values. Results: Forty-two patients with unilateral high-grade internal carotid artery stenosis without stroke were enrolled (26 males, age = 74 ± 9 years, education = 16 ± 3 years). Average composite Z-score was -0.31 SD below the age-specific normative mean (range -2.8 to +1.2 SD). In linear regression adjusted for age, education, and depression, MFV correlated with cognitive Z-score (β = 0.308, p = 0.043). A single breakpoint in the range of composite Z-scores was identified at 45 cm/s. For MFV < 45 cm/s, Z-score decreased 0.05 SD per cm/s MFV (95% CI: 0.01-0.10). For MFV > 45 cm/s, Z-score change was nonsignificant (95% CI: -0.07 to 0.05). Conclusions: In high-grade, asymptomatic carotid artery stenosis, cognitive impairment correlated linearly with lower flow in the hemisphere fed by the occluded internal carotid artery, but only below a threshold of MFV = 45 cm/s. Identifying a hemodynamic threshold for cognitive decline using a simple, noninvasive method may influence revascularization decision-making in otherwise "asymptomatic" carotid disease.

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Section: Discussionmentioning

confidence: 99%

Section: Discussion/conclusionmentioning

confidence: 99%

Cognitive Impairment Correlates Linearly with Mean Flow Velocity by Transcranial Doppler below a Definable Threshold

Marshall

Pavol

Cheung

et al. 2020

Cerebrovasc Dis Extra

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“…7,25 Since GPCirAs are located in the posterior fossa, their mass effect predominantly affects the brainstem and adjacent cranial nerves. 2,27 They usually cause clinical symptoms such as cranial nerve deficits (CNDs), motor deficits, hydrocephalus, and different degrees of disability. 2,13,16,18 They also frequently present with partial thrombosis (PT) and have various shapes.…”

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confidence: 99%

“…6,9 Previously published series describing brainstem compression by posterior circulation aneurysms either predominantly examined nongiant posterior circulation aneurysms or did not analyze GPCirA as a separate size category. 15,27 So far, there has been no systematic analysis of factors associated with CNDs, motor deficits, or disability in patients with GPCirAs and no detailed description of different degrees of brainstem compression or displacement caused by these large lesions. In other diseases, such as basilar invagination (BI), brainstem compression or displacement has been studied and correlated to clinical findings.…”

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confidence: 99%

Giant intracranial aneurysms of the posterior circulation and their relation to the brainstem: analysis of risk factors for neurological deficits

Lenga

Hohaus

Hong

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Giant posterior circulation aneurysms (GPCirAs) usually cause substantial mass effect on the brainstem, which may lead to neurological deficits. So far, there has been no systematic investigation of factors associated with such deficits in GPCirA. The authors aim to examine the risk factors for cranial nerve deficit (CND), motor deficit, and disability in patients with GPCirA. METHODS Using MR images obtained in 30 patients with unruptured GPCirA, the authors examined GPCirA volume, presence of hydrocephalus or partial thrombosis (PT) of the aneurysm, and the degree of brainstem displacement measured by the distance between the McRae line and the tip of the GPCirA (∆MT). They evaluated associations between these factors and neurological deficits. RESULTS Thirty GPCirAs in 30 patients were included. The prevalence of CNDs was 50%. Patients with CNDs significantly differed from those without CNDs in terms of age (mean 51.0 years [SD 15.0 years] vs 69.0 years [SD 21.0 years], p = 0.01) and in ∆MT (median 50.7 mm [IQR 39.2-53.9 mm] vs 39.0 mm [IQR 32.3-45.9 mm], p = 0.02). The prevalence of motor deficits was 33.3%. Patients with motor deficits showed a larger ∆MT (median 50.5 mm [IQR 40.8-54.6 mm]) compared with those without (∆MT: median 39.1 mm [IQR 32.8-50.5 mm], p = 0.04). GPCirA volume was larger in patients with poor modified Rankin Scale (mRS) scores (median 14.9 cm [IQR 8.6-18.7 cm]) than in those with mRS scores of 0-2 (median 6.8 cm [IQR 4.4-11.7 cm], p = 0.03). After adjusting for patient age and the occurrence of hydrocephalus or PT, the authors found that higher degrees of disability were significantly associated with aneurysm volume (OR 1.13, 95% CI 1.0-1.3; p = 0.04), but not with ∆MT. The occurrence of CND or motor deficit was not associated with any of the examined variables. There was no correlation between GPCirA volume and ∆MT (r = 0.01, p = 0.96). The prevalence of neurological deficits did not differ between GPCirA at the basilar apex, the basilar trunk, the vertebrobasilar junction, or the vertebral artery. CONCLUSIONS In this study, the neurological condition of the patients was associated only with GPCirA volume and not with the degree of brainstem displacement, the occurrence of PT or hydrocephalus, or the exact location of the GPCirA. These findings highlight the clinical relevance of GPCirA volume and suggest that factors such as brainstem displacement or PT should play less of a role when finding arguments for or against treatment of GPCirA. Clinical trial registration no.: NCT02066493 (clinicaltrials.gov).

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“…Vertebrobasilar non-saccular and dolichoectatic aneurysms (VBDA) are a rare type of intracranial aneurysm and are generally associated with a poor prognosis due to high rates of morbidity and mortality related to stroke, mass effect, and rupture [1-21]. A number of studies have been published to better characterize the natural history of these aneurysms.…”

Section: Introductionmentioning

confidence: 99%

Natural History of Vertebrobasilar Dolichoectatic and Fusiform Aneurysms: A Systematic Review and Meta-Analysis

et al. 2018

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Background and Purpose: Vertebrobasilar non-saccular and dolichoectatic aneurysms (VBDA) are a rare type of aneurysm and are generally associated with poor prognosis. In order to better characterize the natural history of VBDAs, we performed a systematic review and meta-analysis of the literature to determine rates of mortality, growth, rupture, ischemia, and intraparenchymal hemorrhage. Materials and Methods: We searched the literature for longitudinal natural history studies of VBDA patients reporting clinical and imaging outcomes. Studied outcomes included annualized rates of growth, rupture, ischemic stroke, intracerebral hemorrhage (ICH), and mortality. We also studied the association between aneurysm morphology (dolichoectatic versus fusiform) and natural history. Meta-analysis was performed using a random-effects model using summary statistics from included studies. Results: Fifteen studies with 827 patients and 5,093 patient-years were included. The overall annual mortality rate among patients with VBDAs was 13%/year (95% CI 8–19). Patients with fusiform aneurysms had a higher mortality rate than those with dolichoectatic aneurysms, but this did not reach statistical significance (12 vs. 8%, p = 0.11). The overall growth rate was 6%/year (95% CI 4–13). Patients with fusiform aneurysms had higher growth rates than those with dolichoectatic aneurysms (12 vs. 3%, p < 0.0001). The overall rupture rate was 3%/year (95% CI 1–5). Patients with fusiform aneurysms had higher rupture rates than those with dolichoectatic aneurysms (3 vs. 0%, p < 0.0001). The overall rate of ischemic stroke was 6%/year (95% CI 4–9). Patients with dolichoectatic aneurysms had higher ischemic stroke rates than those with fusiform aneurysms, but this did not reach statistical significance (8 vs. 4%, p = 0.13). The overall rate of ICH was 2%/year (95% CI 0–8) with no difference in rates between dolichoectatic and fusiform aneurysms (2 vs. 2%, p = 0.65). Conclusion: In general, the natural history of VBDAs is poor. However, dolichoectatic and fusiform VBDAs appear to have distinct natural histories with substantially higher growth and rupture associated with fusiform aneurysms. These findings suggest that these aneurysms should be considered separate entities. Further studies on the natural history of vertebrobasilar dolichoectatic and fusiform aneurysms with more complete follow-up are needed to better understand the risk factors for progression of these aneurysms.

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Dolichoectatic aneurysms of the vertebrobasilar system: clinical and radiographic factors that predict poor outcomes

Cited by 20 publications

References 16 publications

Cognitive Impairment Correlates Linearly with Mean Flow Velocity by Transcranial Doppler below a Definable Threshold

Cognitive Impairment Correlates Linearly with Mean Flow Velocity by Transcranial Doppler below a Definable Threshold

Giant intracranial aneurysms of the posterior circulation and their relation to the brainstem: analysis of risk factors for neurological deficits

Natural History of Vertebrobasilar Dolichoectatic and Fusiform Aneurysms: A Systematic Review and Meta-Analysis

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