Proximal Extracranial Vertebral Artery Disease in the New England Medical Center Posterior Circulation Registry

Wityk, Robert J.; Chang, Hui Meng; Rosengart, Axel J.; Han, Wen-Chaing; DeWitt, L. D.; Pessin, Michael S.; Caplan, Louis R.

doi:10.1001/archneur.55.4.470

Cited by 240 publications

(141 citation statements)

References 40 publications

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“…We analyzed and reported the findings among the 80 patients in the registry who had severe occlusive disease (Ͼ75% stenosis or occlusion) of the ECVA in its first segment (between the origin of the artery and penetration into the vertebral column). 88 The great majority of the occlusive lesions, 73 (91%), were due to atherosclerosis, while 6 patients had dissections, and 1 patient had a large aneurysm of the proximal ECVA caused by previous insertion of a jugular line into the artery. ECVA disease was often accompanied by intracranial occlusive disease.…”

Section: Vascular Occlusive Lesionsmentioning

confidence: 96%

“…The 13th patient had bilateral internal carotid artery occlusion and unilateral severe ECVA disease. 88 Angiography often showed occlusion of the ECVA at its origin, with well-developed collateral circulation from the external carotid and the thyrocervical and costocervical arteries ( Figure 9). ECVA surgery can be performed safely by surgeons experienced in the procedure, 89 but we still do not know which patients are surgical candidates.…”

Section: Vascular Occlusive Lesionsmentioning

confidence: 99%

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Posterior Circulation Ischemia: Then, Now, and Tomorrow

Caplan

2000

Stroke

173

103

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know and appreciate where we are now and where we are going in the future, it is essential to know where we have been. We cannot afford to relive and repeat the history of stroke every several decades. Posterior circulation stroke represents a microcosm of stroke in general. In this presentation I first review the development of ideas regarding brain and posterior circulation ischemia and its recognition and treatment. I then share some recent data from a large prospective registry of patients with posterior circulation ischemia. Finally, I look ahead to reflect on what I believe should be the future directions for research and for the care of patients with posterior circulation disease.Patients who present to physicians and hospitals with symptoms that suggest posterior circulation ischemia are handled differently from patients who have symptoms that suggest anterior circulation disease in the great majority of medical facilities in the United States and in the world. A patient who has an attack of dizziness with diplopia and ataxic gait usually has a brain image but seldom has vascular or cardiac investigations. A diagnosis of "vertebrobasilar insufficiency" (VBI) is often made, and physicians then debate whether or not to treat with warfarin-type anticoagulants, and, if so, for how long and at what intensity. In contrast, a patient who has right-hand weakness and aphasia is usually evaluated and treated quite differently at the very same facilities. Brain imaging, cardiac investigations, noninvasive vascular tests of the carotid and intracranial anterior circulation with the use of extracranial and transcranial ultrasound and/or MR angiography (MRA) and CT angiography, and catheter angiography are often pursued, depending on the local technological capabilities and experience of the treating physicians. An effort is made to identify the etiology and mechanism of the ischemia. Treatment is then chosen among a variety of possibilities (including carotid artery surgery, angioplasty, anticoagulants, and antiplatelet aggregants) depending on the nature, location, and severity of the occlusive disease and the mechanism of ischemia.Why should anterior and posterior circulation ischemia be handled so differently? Does this schizophrenic approach make sense? After all, the internal carotid artery and its branches and the vertebral (VA) and basilar arteries (BA) and their branches are just a few inches apart; they are made of the same coats and look the same under the microscope except for size. These vessels carry the same blood under the same blood pressure. The diseases that affect the blood vessels in the 2 circulations are the same. Do stroke mechanisms really differ between the 2 circulations? How did this differing approach originate, and does it continue to make sense today? These are some questions that I will attempt to answer as I review the development of ideas about posterior circulation ischemia and as I report recent data. Development of IdeasHerein I review how knowledge about the posterior circulation ...

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Section: Vascular Occlusive Lesionsmentioning

confidence: 96%

Section: Vascular Occlusive Lesionsmentioning

confidence: 99%

Posterior Circulation Ischemia: Then, Now, and Tomorrow

Caplan

2000

Stroke

173

103

View full text Add to dashboard Cite

show abstract

“…[300][301][302][303] A study using contrast-enhanced MRA in consecutive patients with posterior circulation TIA or minor stroke found a prevalence of >50% vertebral and basilar arterial stenosis, and vertebrobasilar arterial stenosis was more often associated with multiple ischemic episodes and a higher risk of early recurrent stroke. 304 …”

Section: Epidemiology Of Vertebral Artery Diseasementioning

confidence: 99%

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

Brott

Halperin

Abbara

et al. 2011

Cathet Cardio Intervent

185

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“…[3,26] Embolism from distant sites accounts for approximately 40 to 50% of these strokes, with the remainder secondary to atherosclerotic occlusive disease. [6,28] Symptomatic VB atherosclerotic occlusive disease can be associated with significant morbidity and mortality rates in up to 50% of patients. [3,24] Additionally, extra-and intracranial atherosclerotic disease is a significant predictor of extensive systemic disease and especially coronary artery disease.…”

Section: Discussionmentioning

confidence: 99%

Stent placement for vertebral artery occlusive disease: preliminary clinical experience

Fessler¹,

Wakhloo²,

Lanzino³

et al. 1998

FOC

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Symptoms of vertebrobasilar insufficiency may precede neurological sequelae in up to 50% of patients. Although select patients may benefit from microsurgical revascularization, combined perioperative morbidity and mortality rates can be as high as 20%. The authors present their preliminary clinical experience using stent placement for symptomatic vertebral artery (VA) occlusive disease. Six patients with clinical symptoms of vertebrobasilar insufficiency in whom VA stents were placed from 1995 to 1998 were identified. Diagnostic four-vessel cerebral angiography identified causative stenotic, atherosclerotic lesions in all cases. A transfemoral or transradial artery approach after the patient had undergone full heparinization was chosen for endovascular stenting. Guidewire placement across the lesion followed by urokinase infusion preceded stenting. Prestent angioplasty was performed in two patients. Following the procedure, all patients were maintained on daily antiplatelet therapy. Patient age ranged from 45 to 76 years (average 63 years). Four patients were men and two were women. Angiography revealed greater than 95% stenosis in five patients and greater than 70% stenosis in one. Three patients had complete occlusion of the contralateral VA; in one other, the VA supplied only the posterior inferior cerebellar artery; and the remaining two patients had VAs with greater than 70% stenosis. Ten stents were placed in six patients for five VA origin lesions and one distal VA stenosis. A VA dissection occurring poststenting was treated by placement of three additional stents. One patient had transient double vision. All had resolution of their presenting symptoms. Follow up ranged from 1 to 24 months (average 8.4 months). Angiograms obtained in four patients at least 3 months postprocedure have revealed stent patency in all cases without evidence of restenosis. Vertebral artery stent placement can be safely performed and is a viable treatment option for carefully selected patients with vertebrobasilar insufficiency.

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Proximal Extracranial Vertebral Artery Disease in the New England Medical Center Posterior Circulation Registry

Cited by 240 publications

References 40 publications

Posterior Circulation Ischemia: Then, Now, and Tomorrow

Posterior Circulation Ischemia: Then, Now, and Tomorrow

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

Stent placement for vertebral artery occlusive disease: preliminary clinical experience

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