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Patterns of ischemic posterior circulation strokes: A clinical, anatomical, and radiological review.International Journal of Stroke :... Aug 2022Posterior circulation and anterior circulation strokes share many clinical, pathogenetic and radiological features, although some clinical signs are highly specific to... (Review)
Review
BACKGROUND
Posterior circulation and anterior circulation strokes share many clinical, pathogenetic and radiological features, although some clinical signs are highly specific to posterior circulation strokes. Arterial stenosis and occlusions occur in significant numbers in both acute posterior circulation and anterior circulation strokes, making them good candidates for endovascular treatment. Among posterior circulation strokes, basilar artery occlusions stand out because of the diagnostic and acute treatment challenges.
METHODS
We reviewed the literature on clinical stroke syndromes and neuroimaging findings and systematically describe for each anatomical site of stroke the detailed clinical and radiological information (anatomical representation, diffusion weighted imaging and angiographic sequences). The principles of neuroimaging of posterior circulation strokes and the prognosis for each stroke localization are also discussed.
REVIEW SUMMARY
Stroke syndromes in the territories of the vertebral, basilar, cerebellar, and posterior cerebral arteries are presented. Features typical of posterior circulation strokes are highlighted, including patterns of basilar artery occlusions. Clinical severity and prognosis of posterior circulation strokes are highly variable, and given that they are more difficult to detect on CT-based neuroimaging, magnetic resonance imaging is the technique of choice in suspected posterior circulation strokes. Rapid identification of arterial occlusion patterns may provide prognostic information and support acute revascularization decisions.
CONCLUSIONS
Posterior circulation stroke syndromes tightly reflect lesion localization and arterial occlusion patterns. Although many clinical and pathogenetic features are similar to anterior circulation strokes, notable differences exist in terms of clinical presentation, stroke mechanism, prognosis, and response to acute recanalization.
Topics: Arterial Occlusive Diseases; Basilar Artery; Humans; Ischemic Stroke; Retrospective Studies; Stroke; Syndrome; Vertebrobasilar Insufficiency
PubMed: 34581223
DOI: 10.1177/17474930211046758 -
Journal of the American Heart... Jan 2016Radial artery occlusion (RAO) may occur posttransradial intervention and limits the radial artery as a future access site, thus precluding its use as an arterial... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Radial artery occlusion (RAO) may occur posttransradial intervention and limits the radial artery as a future access site, thus precluding its use as an arterial conduit. In this study, we investigate the incidence and factors influencing the RAO in the current literature.
METHODS AND RESULTS
We searched MEDLINE and EMBASE for studies of RAO in transradial access. Relevant studies were identified and data were extracted. Data were synthesized by meta-analysis, quantitative pooling, graphical representation, or by narrative synthesis. A total of 66 studies with 31 345 participants were included in the analysis. Incident RAO ranged between <1% and 33% and varied with timing of assessment of radial artery patency (incidence of RAO within 24 hours was 7.7%, which decreased to 5.5% at >1 week follow-up). The most efficacious measure in reducing RAO was higher dose of heparin, because lower doses of heparin were associated with increased RAO (risk ratio 0.36, 95% CI 0.17-0.76), whereas shorter compression times also reduced RAO (risk ratio 0.28, 95% CI 0.05-1.50). Several factors were found to be associated with RAO including age, sex, sheath size, and diameter of radial artery, but these factors were not consistent across all studies.
CONCLUSIONS
RAO is a common complication of transradial access. Maintenance of radial patency should be an integral part of all procedures undertaken through the radial approach. High-dose heparin along with shorter compression times and patent hemostasis is recommended in reducing RAO.
Topics: Aged; Anticoagulants; Arterial Occlusive Diseases; Catheterization, Peripheral; Chi-Square Distribution; Dose-Response Relationship, Drug; Female; Heparin; Humans; Incidence; Male; Middle Aged; Odds Ratio; Punctures; Radial Artery; Risk Factors; Vasoconstriction
PubMed: 26811162
DOI: 10.1161/JAHA.115.002686 -
Translational Stroke Research Dec 2022Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The... (Review)
Review
Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.
Topics: Humans; Basilar Artery; Vertebrobasilar Insufficiency; Endovascular Procedures; Treatment Outcome; Thrombectomy; Arterial Occlusive Diseases; Stroke; Retrospective Studies; Thinking; Infarction
PubMed: 35349051
DOI: 10.1007/s12975-022-01008-5 -
JACC. Cardiovascular Interventions May 2022
Topics: Arterial Occlusive Diseases; Cardiac Catheterization; Catheterization, Peripheral; Humans; Radial Artery; Treatment Outcome
PubMed: 35331685
DOI: 10.1016/j.jcin.2022.03.008 -
Association of Palmar Arch Collateral Function and Radial Artery Occlusion After Transradial Access.The American Journal of Cardiology Apr 2022The prevalence and implications of radial artery occlusion (RAO) after transradial catheterization are an intensely discussed topic, resulting in numerous preventive...
The prevalence and implications of radial artery occlusion (RAO) after transradial catheterization are an intensely discussed topic, resulting in numerous preventive strategies such as adjusted anticoagulation, residual-patency hemostasis, or distal puncture site. The present study aimed at assessing an association of palmar arch, in particular radial artery collateral function and RAO after transradial access (TRA) catheterization. Radial artery collateral function was determined using radial artery pressure signals in the nonobstructed vessel and during brief manual occlusion of the more proximal radial artery. Collateral flow index, the ratio of mean occlusive divided by mean nonocclusive arterial blood pressure, both subtracted by central venous pressure, was determined during manual RAO (radial artery collateral flow index [CFI]). The presence or absence of RAO was determined by Doppler ultrasound at least 3 months after TRA. A total of 630 patients with TRA coronary angiography underwent palmar arch, that is, radial and radial plus ulnar artery collateral function assessment. CFI was equal to 0.808 ± 0.144 (95% confidence interval 0.797 to 0.819). A total of 200 patients underwent Doppler ultrasound examination of their forearm arterial circulation 301 ± 140 days after TRA. Eight (4%) patients showed signs of RAO, 4 of whom (2%) had a complete RAO and 4 (2%) a stenosis above 30%. Patients with RAO showed a higher CFI than those without RAO: 0.900 ± 0.074 versus 0.801 ± 0.154 (p = 0.006). In conclusion, complete RAO as determined by Doppler ultrasound later than 3 months after TRA is rare (2%). In the long run, RAO appears to be related to a very well-developed radial artery collateral function.
Topics: Arterial Occlusive Diseases; Cardiac Catheterization; Coronary Angiography; Hand; Humans; Punctures; Radial Artery
PubMed: 35065801
DOI: 10.1016/j.amjcard.2021.12.020 -
Clinical Research in Cardiology :... Sep 2023This study investigated the contemporary incidence and predictors of radial artery occlusion as well as the effectiveness of antithrombotic treatment for radial artery... (Clinical Trial)
Clinical Trial
OBJECTIVES
This study investigated the contemporary incidence and predictors of radial artery occlusion as well as the effectiveness of antithrombotic treatment for radial artery occlusion following transradial coronary angiography.
BACKGROUND
The radial artery is the standard access for coronary angiography and even complex interventions. Postprocedural radial artery occlusion is still a common and significant complication.
METHODS
This prospective study enrolled 2004 patients following transradial coronary angiography. After sheath removal, hemostasis was obtained in a standardized fashion. Radial artery patency was evaluated by duplex ultrasonography in all patients. In case of occlusion, oral anticoagulation was recommended and patients were scheduled for a 30-day follow-up including Doppler ultrasonography.
RESULTS
A new-diagnosed radial occlusion was found in 4.6% of patients. The strongest independent predictors of radial occlusion were female sex and active smoking status. In the subgroup of patients with percutaneous coronary interventions, female sex followed by sheath size > 6 French were the strongest predictors of radial occlusion. 76 of 93 patients with radial occlusion received an oral anticoagulation for 30 days. However, reperfusion at 30 days was found in 32% of patients on oral anticoagulation.
CONCLUSION
The incidence of radial artery occlusion following coronary angiography in contemporary practice appears with 4.6% to be lower as compared to previous cohorts. Female sex and smoking status are the strongest independent predictors of radial occlusion followed by procedural variables. The limited effectiveness of oral anticoagulation for treatment of radial artery occlusion suggests a primarily traumatic than thrombotic mechanism of this complication.
Topics: Female; Humans; Male; Anticoagulants; Arterial Occlusive Diseases; Coronary Angiography; Incidence; Prospective Studies; Radial Artery
PubMed: 36074269
DOI: 10.1007/s00392-022-02094-z -
Clinical Cardiology Dec 2022Radial artery spasm (RAS) is the most common cause of transradial access site crossover and is a common intra-procedural complication. RAS incidence can lead to radial... (Meta-Analysis)
Meta-Analysis Review
The efficacy of nitroglycerin to prevent radial artery spasm and occlusion during and after transradial catheterization: A systematic review and meta-analysis of randomized controlled trials.
Radial artery spasm (RAS) is the most common cause of transradial access site crossover and is a common intra-procedural complication. RAS incidence can lead to radial artery occlusion (RAO) postprocedure, preventing the radial artery as a future access site. We evaluated the efficacy of nitroglycerin preventing RAS and RAO during transradial catheterization discussing the different routes of administration, including topical, subcutaneous, and intra-arterial. A systematic review and meta-analysis included all relevant articles until April 23, 2022. We searched six databases Google Scholar, Web of Science, SCOPUS, EMBASE, PubMed (MEDLINE), and CENTRAL. We registered our review protocol in PROSPERO with ID: CRD42022330356. We included 11 trials with 5814 patients. Compared to placebo, the pooled analysis favored subcutaneous nitroglycerin in preventing RAS (risk ratio [RR]: 0.57 with 95% confidence interval [CI] [0.43-0.77], p = .0003) and RAO (RR: 0.39 with 95% CI [0.16-0.98], p = .05). In contrast to the intra-arterial nitroglycerin that showed nonstatistically significant results in preventing RAS and RAO (RR: 0.8 with 95% CI [0.63-1.02], p = .07)- (RR: 0.78 with 95% CI [0.6-1.01], p = .06)), respectively. Also, topical nitroglycerin did not prevent RAS (RR: 0.73 with 95% CI [0.42-1.24], p = .24). Compared with placebo, subcutaneous nitroglycerin during transradial catheterization reduced the incidence of RAS and RAO. Meanwhile, Intra-arterial and topical nitroglycerin did not show statistically significant outcomes. Subcutaneous nitroglycerin may be a practical and cost-effective technique to facilitate transradial catheterization; however, more RCTs are needed to evaluate the subcutaneous versus intra-arterial nitroglycerin administration.
Topics: Humans; Nitroglycerin; Radial Artery; Vasodilator Agents; Randomized Controlled Trials as Topic; Spasm; Arterial Occlusive Diseases; Cardiac Catheterization
PubMed: 36335609
DOI: 10.1002/clc.23906 -
International Heart Journal May 2017To investigate the postprocedural cardiovascular events and vascular outcomes, including hand ischemia and neurological compromise, after transulnar (TU) catheterization...
To investigate the postprocedural cardiovascular events and vascular outcomes, including hand ischemia and neurological compromise, after transulnar (TU) catheterization in ipsilateral radial artery occlusion.Previous randomized trials have shown that the transulnar (TU) approach for coronary angiogram and intervention has safety and outcomes similar to those of the transradial (TR) approach. However, the safety of the TU procedure when ipsilateral radial artery occlusion occurs is unknown.We retrospectively reviewed 87 TU cases with ipsilateral radial artery occlusion confirmed by a forearm angiogram. Eighty percent of these patients had a history of ipsilateral radial artery cannulation or surgery. We avoided the use of over-sized sheaths or applied a sheathless approach during surgery.No ulnar artery occlusion was observed by subsequent Doppler ultrasound or pulse oximetry. No patient developed hand ischemia or serious complications requiring surgery or blood transfusion during the follow-up period of 32.2 ± 24.0 months. Review of the preprocedural forearm angiograms showed that 95.7% of the patients possessed significant collaterals supplying flow from the interosseous artery to the occluded radial artery remnant. Thus, the blood circulation to the palmar arch and digital vessels was maintained even when the ulnar artery was temporarily occluded by an in-dwelling ulnar arterial sheath.TU catheterization was safe in patients with coexisting ipsilateral radial artery occlusions and feasible for use in complex intervention procedures. Cautious manipulation of ulnar artery cannulation and hemostasis helped decrease the risk of hand ischemia.
Topics: Aged; Angiography; Arterial Occlusive Diseases; Catheterization, Peripheral; Feasibility Studies; Female; Follow-Up Studies; Humans; Male; Radial Artery; Retrospective Studies; Treatment Outcome; Ulnar Artery; Ultrasonography, Doppler
PubMed: 28496021
DOI: 10.1536/ihj.16-244 -
Scientific Reports Dec 2023To investigate the incidence and impact of superior cerebellar artery (SCA) occlusion remaining after thrombectomy for acute basilar artery occlusion (BAO). We...
To investigate the incidence and impact of superior cerebellar artery (SCA) occlusion remaining after thrombectomy for acute basilar artery occlusion (BAO). We retrospectively analyzed data from 116 patients who underwent thrombectomy for BAO. The patency of SCA was assessed on final angiograms. Clinical and radiologic data of the patients were retrieved from a prospectively collected database and analyzed. All patients underwent pretreatment and follow-up DWI to detect new infarctions in SCA territory. Ten patients (8.6%) had SCA occlusions on final angiograms. Of these, two patients had bilateral occlusions. A new infarction with a diameter ranged from 4 to 11 mm in corresponding SCA territory occurred in 5 of 10 patients. No patients with SCA occlusions experienced symptomatic cerebellar hemorrhage or malignant cerebellar infarction. Nine of 12 SCA occlusions showed spontaneous recanalization on follow-up CT angiography. Four of 10 patients showed 90-day favorable outcome (mRS 0-3) and 90-day mortality occurred in one patient. SCA occlusions remaining after thrombectomy for acute BAO had a benign clinical course. Most of these lesions recanalized spontaneously. Our study suggests that attempts to recanalize remnant SCA occlusion may be unnecessary after basilar artery thrombectomy.
Topics: Humans; Basilar Artery; Vertebrobasilar Insufficiency; Retrospective Studies; Endovascular Procedures; Treatment Outcome; Thrombectomy; Arterial Occlusive Diseases; Infarction; Stroke
PubMed: 38104225
DOI: 10.1038/s41598-023-50023-5 -
The American Journal of Case Reports May 2018BACKGROUND Aortic occlusion, whether acute or subacute, is a rare but very serious entity with disastrous consequences if not treated in a timely fashion. Rapid...
BACKGROUND Aortic occlusion, whether acute or subacute, is a rare but very serious entity with disastrous consequences if not treated in a timely fashion. Rapid diagnosis is crucial in this setting. In surgically treated patients there is a high degree of mortality and morbidity; therefore, percutaneous revascularization, whenever possible and independent of the available techniques, is much more desirable. CASE REPORT A 62-year-old woman with a history of diabetes mellitus, dyslipidemia, hypertension, and peripheral vascular disease, with previous femoral-femoral bypass for right common iliac artery occlusion, and with recent conventional angiography showing near occlusion of the ostial left common iliac artery (the donor vessel for the previous bypass), was referred to our hospital for conventional angioplasty. We faced were surprised to find a total infrarenal aortic occlusion and decided to perform emergency and rescue recanalization. We successfully recanalized the aorta and left iliac artery by stent implantation and stabilized the patient, considering that surgical intervention has very high risk for morbidity and mortality in this particular setting. CONCLUSIONS Although revascularization is rarely performed in this life-threating condition, endovascular recanalization of a subacute aortic occlusion in a patient with femoral-femoral bypass is feasible and can be life-saving.
Topics: Angiography; Angioplasty; Aorta, Abdominal; Aortic Diseases; Arterial Occlusive Diseases; Blood Vessel Prosthesis Implantation; Female; Humans; Middle Aged; Stents
PubMed: 29784901
DOI: 10.12659/AJCR.907547