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Stroke
Published in Henry J. Woodford, Essential Geriatrics, 2022
A meta-analysis of five trials (n = 1,287; median age 68) found that endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted OR 2.49; 95% CI 1.76–3.53; mRS 0–2 at 90 days 46% v 27%; 90-day mortality 15% v 19%).33 Rates of intracerebral haemorrhage appear similar between groups. Possible adverse events include vessel dissection and groin haematoma formation. A prospective, observational cohort study observed similar outcomes in real world data as those seen in clinical trials.34 Endovascular thrombectomy has been evaluated specifically in people aged over 80 recruited to trials (n = 380).35 Compared to younger adults, they had worse functional outcomes (adjusted OR for better mRS 0.31; 95% CI 0.24–0.39) and mortality after three months (51% v 22%). It may still be considered for selected, previously functionally independent people aged over 80. A similar benefit has not been demonstrated for basilar artery occlusion.36
Anatomy of the head and neck
Published in Helen Whitwell, Christopher Milroy, Daniel du Plessis, Forensic Neuropathology, 2021
The basilar artery has a number of branches: the anterior spinal artery runs inferiorly in the anteromedian groove of the spinal cord; the posteroinferior cerebellar artery runs in the lateral aspect of the medulla and the cerebellum; and two posterior spinal arteries lie medial to the dorsal nerve roots and can arise variably from either the vertebral or the posterior cerebellar vessels. Lying on the ventral surface of the brainstem and the pons, the basilar artery supplies the brainstem and cerebellum through anteroinferior and superior cerebellar arteries. At the superior margin of the pons, the vessel divides into the posterior cerebral arteries, which supply the temporal and occipital lobes of the cortex. The posterior communicating artery (see above) forms the posterior part of the circle of Willis and links the basilar to the internal carotid artery system (Figures 1.4 and 1.5).
Disorders of Consciousness
Published in Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw, Hankey's Clinical Neurology, 2020
Brainstem stroke: Sudden onset.Vascular risk factors or neck trauma (dissection).Asymmetry of long tract signs.Caused by basilar artery occlusion or pontine hemorrhage.More extensive involvement of tegmental structures of pons as well as midbrain and thalamus.
Acute ischemic stroke management: concepts and controversies.A narrative review
Published in Expert Review of Neurotherapeutics, 2021
Ka Hou Christien Li, Aaron Jesuthasan, Christopher Kui, Ruth Davies, Gary Tse, Gregory Y. H. Lip
Given the severe prognosis of basilar occlusions [56], data on this subset of patients will be vital in optimizing therapeutic decision-making. The BASICS study did provide some supplementary data on this front but an adequately powered randomized controlled trial investigating this is needed [57]. Several systematic meta-analyses of case series and registry data suggest that MT provides a better outcome in patients with basilar artery occlusion (BAO) [58–60]. This notion is especially promising when considered in conjunction with the recent non-randomized Acute Basilar Artery Occlusion Study (BASILAR) [61], which reported better functional and safety outcomes in patients receiving standard medical treatment plus endovascular therapy compared to those receiving standard medical treatment.
Clinical considerations and assessment of risk factors when choosing endovascular thrombectomy for acute stroke
Published in Expert Review of Cardiovascular Therapy, 2020
Ankur Wadhwa, Raed Joundi, Bijoy Menon
Data from the HERMES study showed that almost a quarter of octogenarians showed good outcome at 90 days and a third died. Excellent rates of reperfusion nearing 80% were achieved with rates of symptomatic intracranial hemorrhages being less than 10% [91]. In another systematic review and metanalysis, although outcomes were inferior to younger patients, good functional outcome still occurred in 27% of elderly [92]. Given the growing elderly population and increasing life expectancy, further work needs to be done in this area. However, at this point it would be reasonable to conclude that age alone should not be an exclusionary factor in offering beneficial therapies to patients with acute stroke. Basilar artery occlusions (BAO)
Bilateral Fascicular Third Nerve Palsy in Posterior Circulation Stroke
Published in Neuro-Ophthalmology, 2019
Olaf Eberhardt, Mirjam Hermisson, Gisela Eberle-Strauss, Helge Topka
No angiographic or neurosonological pathology affecting the left vertebral artery was shown, in particular no signs of vertebral artery dissection. A diagnostic work-up to identify the source of embolic basilar artery occlusion made a cardioembolic origin probable. Transcranial ultrasound studies after agitated saline had been injected intravenously revealed a single embolic signal at rest and about 20 embolic signals following Valsalva manoeuvre. Right-to-left shunt following Valsalva manoeuvre due to patient foramen ovale was confirmed by transoesophageal echocardiography. A hypermobile septal aneurysm was present, but there was no intracardiac thrombus or aortic atheroma. Left ventricular function and flow velocity in the left atrial appendage were normal. Importantly, no crural venous thrombosis was detected by duplex ultrasonography. Apart from a single supraventricular run over only seven beats no relevant cardiac arrhythmia was detected in several 24-h electrocardiographies. Blood lipids, coagulation screening, and other blood tests were unremarkable, except for slight hyperuricaemia. Therapy with acetylsalicylic acid and a statin was initiated.