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Cervical vertebral angioplasty for brain stem ischemia
Insights
Vertebral artery reconstruction safely treats brain stem ischemia and syncopal episodes when carotid lesions are corrected. This procedure shows a low stroke rate, but long-term survival is impacted by other health conditions.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiology
Background:
- Extracranial arterial occlusive disease can cause stroke and transient ischemic attacks.
- Vertebral artery stenosis is a significant cause of vertebrobasilar insufficiency, leading to brain stem symptoms.
- Surgical intervention for vertebral artery disease has evolved, with varying indications and outcomes.
Purpose of the Study:
- To evaluate the long-term outcomes of unilateral vertebral arterial reconstructions.
- To assess the safety and efficacy of vertebral angioplasty for specific neurological symptoms.
- To determine the indications and effectiveness of vertebral procedures in patients with persistent symptoms after carotid intervention.
Main Methods:
- A retrospective review of 58 patients undergoing unilateral vertebral arterial reconstructions over 16 years.
- Analysis of procedures including subclavian-vertebral angioplasty and bypass grafting.
- Evaluation of patient symptoms, co-existing conditions, and long-term follow-up data including stroke rates and survival.
Main Results:
- Vertebral reconstruction, primarily subclavian-vertebral angioplasty, was performed for brain stem symptoms and persistent ischemia after carotid repair.
- Syncopal episodes were a major symptom, often controlled by vertebral procedures, though cardiac interventions were sometimes necessary.
- Long-term follow-up showed a low stroke rate (1.2% per patient-year) and sustained neurological stability in 70% of patients at 14 years, but overall survival was 45%, with myocardial infarction as the leading cause of death.
Conclusions:
- Vertebral angioplasty is indicated for bilateral vertebral arterial flow-obstructing lesions in patients with brain stem ischemia, especially when symptoms persist after carotid lesion correction.
- The procedure can be performed with a high degree of safety.
- Differential diagnosis for drop attacks and syncope should include cardiac arrhythmias, aortic stenosis, and convulsive disorders alongside vertebrobasilar insufficiency.
Abstract:
Fifty-eight patients underwent unilateral vertebral arterial reconstructions over a 16-year period. Thirty-four underwent carotid operations as well. The first 18 patients underwent vertebral arterial reconstructions in conjunction with carotid endarterectomy as mandated in the Joint Study of Extracranial Arterial Occlusion as a Cause of Stoke. The next 40 underwent vertebral procedures for either brain stem symptoms alone, or for combined cerebral cortical and stem symptoms for specific indications after flow-obstructing carotid lesions had been corrected, but symptoms failed to subside. The surgical procedure consisted of subclavian-vertebral angioplasty except in one patient who underwent a subclavian distal-vertebral bypass graft to the level of the second cervical vertebral body. Syncopal episodes occurred as a major symptom in 16 and was controlled by either carotid and vertebral or vertebral artery operation alone except in four who also required cardiac pacemakers and one who needed correction of aortic stenosis. The long-term follow-up reveals that the stroke rate per average year for the first 14 years of follow-up was 1.2% per patient year with only five strokes having occurred in 410 patient years of follow-up and 70% of the patients having sustained no new neurologic episodes at the fourteenth year. Survival, however, was 45% at the fourteenth year with most deaths caused by myocardial infarction. The surgical procedure of vertebral angioplasty is indicated when bilateral vertebral arterial flow-obstructing lesions are found in patients with brain stem ischemia including drop attacks and syncopal episodes if flow-obstructing carotid lesions have been corrected and symptoms persist. The surgical procedure can be performed with a high degree of safety. The differential diagnosis of drop attacks and syncope in this age group should include, in addition to vertebrobasilar arterial insufficiency, transient cardiac arrhythmias, aortic stenosis, and convulsive disorders.