An Unusual Cause of Vertebral Artery Dissection: Esophagogastroduodenoscopy

Brain-supplying arterial dissection is considered one of the most common vascular causes of stroke in younger patients. Dissections are usually preceded by trauma or mechanical stress; the vascular stressor may be trivial as this condition has been described in association with manipulation and stretching the neck. Here we describe a case of vertebral artery dissection and stroke following esophagogastroduodenoscopy. This case highlights a potentially serious complication that may occur after procedures that require hyperextension of the neck

Aphasia after Left Thalamic Infarction

We Examined a 70-Year-Old Woman Who Became Aphasic after a Left Thalamic Infarction. Computed Tomographic Scan Showed Injury that Was Largely Limited to the Ventral Anterior and Rostral Ventral Lateral Thalamic Nuclei. Speech Was Characterized by Reduced Voice Volume, Impaired Auditory and Reading Comprehension, Perseverations, Intermittent Use of Jargon, Fluctuations in the Ability to Perform Confrontation Naming, Extraneous Intrusions, Verbal Paraphasia, Intact Repetition Skills, and Fluent Speech that Was Laconic But Grammatically Correct. We Propose that the Deficits after Left Thalamic Injury Can Be Grouped into the Following Four Large Clusters: Extrapyramidal Deficits (Decreased or Fading Voice Volume), Deficits in Lexical Access (Anomia, Verbal Paraphasia), Deficits in Vigilance (Neologisms, Intrusions, Fluctuating Performance, Jargon, Perseverations), and Comprehension Defects. © 1984, American Medical Association. All Rights Reserved

Advances in Our Understanding of “Resistance” to Antiplatelet Agents for Prevention of Ischemic Stroke

We review the role of aspirin and clopidogrel for prevention of ischemic stroke and explore the concept of antiplatelet therapy resistance both from a laboratory and clinical perspective and genetic polymorphisms that might influence platelet reactivity with clopidogrel administration. Debates have raged over the years about the application of platelet function tests in clinical practice. We conclude that platelet function testing is not indicated in routine clinical practice. This recommendation is supported by clinical guideline statements, a lack of a global platelet function measure, and limitations of current platelet function test methods as applied in practice. We discuss a recently hypothesized hierarchy of patient characteristics in relation to which patients are most likely to benefit from platelet function studies based on acuity (i.e., risk) of cardiovascular disease. A focus of antiplatelet therapy administration should include emphasis on compliance/adherence and in the example of aspirin, use of well-absorbed forms of aspirin and avoidance of drugs that may interact with aspirin to inhibit its mechanism of action (e.g., certain nonsteroidal anti-inflammatory drugs)

Racial Differences in the Distribution of Posterior Circulation Occlusive Disease

We Compared Clinical and Arteriographic Features in 27 White and 24 Black Patients with Symptomatic Posterior Circulation Occlusive Disease. the Degree of Arterial Stenosis Was Measured Independently by Two Examiners at 12 Sites within the Vertebrobasilar Territory. Racial Comparisons Were Made based Upon the Distribution of Extra- and Intracranial Occlusive Lesions and Symptomatic Sites of the Lesions. White Patients Had Significantly More Angina Pectoris, More Lesions of the Origin of the Left Vertebral Artery and More High-Grade Lesions of the Extracranial Vertebral Arteries. Black Patients Had Significantly Higher Mean Diastolic Blood Pressure, More Diabetes Mellitus, More Lesions of the Distal Basilar Artery, More High-Grade Lesions of Intracranial Branch Vessels and More Symptomatic Intracranial Branch Disease. Race Was Found to Be the Only Factor Increasing the Risk of Intracranial Posterior Circulation Occlusive Disease. Knowledge of the Contribution of Race to the Distribution of Posterior Circulation Lesions Will Help Guide Evaluation and Treatment Strategies for Patients with Vertebrobasilar Occlusive Disease. © 1985 American Heart Association, Inc

Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier

BACKGROUND AND PURPOSE: Large artery intracranial occlusive disease (LAICOD) is a common and important stroke subtype. In this commentary, we review key epidemiological aspects of LAICOD. SUMMARY OF REVIEW: LAICOD has emerged as the most common stroke subtype worldwide and is associated with a high risk of recurrent stroke. Hypotheses have been proposed to explain causation, which include such factors as traditional cardiovascular risk factors, high blood volume states, and genetic abnormalities. Approaches to treatment such as antithrombotic therapies, revascularization procedures, and counterpulsation devices hold promise. CONCLUSIONS: LAICOD poses a major stroke problem worldwide and is likely the most common stroke subtype. The etiology and treatment of this disorder remain poorly defined. International collaborations are needed to pool collective knowledge and develop definitive studies to better understand causation and treatment of LAICOD

Natural History of Hemodynamics in Vertebrobasilar Disease: Temporal Changes in the VERiTAS Study Cohort.

BACKGROUND AND PURPOSE: The role of regional hypoperfusion as a contributor to stroke risk in atherosclerotic vertebrobasilar disease has recently been confirmed by the observational VERiTAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) Study. We examined the stability of hemodynamic status over time and its relationship to stroke risk in patients from this prospective cohort. METHODS: VERiTAS enrolled patients with recently symptomatic ≥50% atherosclerotic stenosis/occlusion of vertebral and/or basilar arteries. Large vessel flow in the vertebrobasilar territory was assessed using quantitative magnetic resonance angiography, and patients were designated as low or normal flow based on distal territory regional flow, incorporating collateral capacity. Patients underwent standard medical management and follow-up for primary outcome event of vertebrobasilar territory stroke. Quantitative magnetic resonance angiography imaging was repeated at 6, 12, and 24 months. Flow status over time was examined relative to baseline and relative to subsequent stroke risk using a cause-specific proportional hazard model, with flow status treated as a time-varying covariate. Mean blood pressure was examined to assess for association with changes in flow status. RESULTS: Over 19±8 months of follow-up, 132 follow-up quantitative magnetic resonance angiography studies were performed in 58 of the 72 enrolled patients. Of the 13 patients with serial imaging who had low flow at baseline, 7 (54%) had improvement to normal flow at the last follow-up. Of the 45 patients who had normal flow at baseline, 3 (7%) converted to low flow at the last follow-up. The mean blood pressure did not differ in patients with or without changes in flow status. The time-varying flow status remained a strong predictor of subsequent stroke (hazard ratio, 10.3 [95% CI, 2.2-48.7]). CONCLUSIONS: There is potential both for improvement and worsening of hemodynamics in patients with atherosclerotic vertebrobasilar disease. Flow status, both at baseline and over time, is a risk factor for subsequent stroke, thus serving as an important prognostic marker. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT00590980