Vertebrobasilar Ischemia and Hemorrhage

 

Description:

This comprehensive review of vascular disease in the vertebrobasilar circulation is based on Dr Louis R. Caplan's extensive experience and observation of patients from the New England Medical Center posterior circulation stroke registry. It benefits from an organized, uniform, and coherent analysis of all types of vascular disease involving the posterior circulation, presented by a single author who is one of the world's leading authorities on this topic. This new edition is fully updated throughout, including a review of all the literature published on this topic since the previous edition in 1996. There are major rewrites for the chapters on diagnosis and therapy, inclusion of modern imaging techniques, and extensive illustrations. Essential reading for stroke physicians and neurologists, the book will also be an important source of reference for neurosurgeons, vascular surgeons and endovascular radiologists.

 

Table of Contents:

 

Section I General Features of Cerebrovascular Disease in the Posterior Circulation

1 Historical background

Early history

Anatomy and pathology: the sixteenth, seventeenth, and eighteenth centuries

The nineteenth and early twentieth centuries

Development of knowledge about the causes of stroke

Ischemia

Hemorrhage

The modern era (1975–present)

Advances in diagnostic technology

Stroke data banks and registries

Stroke units, stroke specialists, and stroke nurses

Advances in medical and surgical therapy and randomized trials

Acute reperfusion using thrombolytic drugs, thrombus removal with devices, and direct angioplasty and stenting

Interventional techniques to treat potential bleeding cranial lesions: aneurysms and vascular malformations

Posterior circulation strokes

Hemorrhage

Pontine hemorrhage

Cerebellar hemorrhage

Ischemia

2 Basic anatomy and pathology

Brain anatomy

Brainstem and thalamus

Medulla oblongata

Pons

Midbrain

Thalamus

Cerebellum–

Posterior portions of the cerebral hemispheres

Arterial anatomy

Extracranial large arteries

Intracranial large arteries and their branches

Intracranial vertebral artery (ICVA) and branches

Basilar artery

Section

Posterior cerebral arteries (PCAs) and their branches

Arterial supply regions

Venous anatomy

Vascular pathology

Large artery atherosclerosis

Penetrating small artery disease

Arterial dissections

Embolism

Dolichoectasia (dilatative arteriopathy)

Fibromuscular dysplasia (FMD)

Arterial aneurysms and subarachnoid hemorrhage (SAH)

Vascular malformations

Parenchymal hemorrhage (ICH)

Venous occlusions

Systemic hypotension and hypoperfusion

Other less common vasculopathies

Drugs, especially cocaine

MELAS syndrome

Vasculitis

Giant cell (granulomatous, temporal) arteritis

Takayasu disease

Behçet’s disease

Arteritis caused by infectious agents

3 Signs and symptoms and their clinical localization

Visual perception and related deficits

Visual field defects

Visual inattention and neglect

Abnormal visual perceptions and distortions

Complex disorders of visual perception

Lower bank bilateral lesions

Upper bank bilateral lesions

Abnormalities of depth perception

Disorientation for place and space

Other cognitive and behavioral abnormalities including agnosias, alexia, and aphasia

Left hemisphere lesions, including the thalamus

Reading abnormalities

Aphasia

Visual agnosia and visual anomia

Right hemispheral lesions including the thalamus

Abnormal drawing and copying

Visual amnesia and visual hypoemotionality

Nonvisual behavioral and cognitive abnormalities most often associated with bilateral cerebral hemispheral or thalamic lesions

Abulia

Amnesia

Agitation with delirium

Reduced level of consciousness

Anatomy and physiology

Intrinsic brainstem vascular lesions and coma

Extrinsic lesions

Motor abnormalities

Limb abnormalities and gait

Thalamic lesions

Midbrain lesions

Pontine lesions

Medullary lesions

Cerebellum

Movement disorders

Bulbar muscle motor abnormalities

Vestibular and oculomotor abnormalities

The vestibuloocular reflex and its abnormalities

Vestibular and oculomotor abnormalities at various anatomical loci

Lateral medullary and lateral pontine tegmental lesions

Unilateral medial pontine tegmental lesions

Bilateral medial pontine tegmental lesions

Midbrain lesions

Mesencephalic–diencephalic junction and diencephalic lesions

Cerebellar lesions

Sensory abnormalities

Somatosensory

Limbs and trunk

Face and head

Hearing

Taste

Pupillary size and reactivity

Autonomic dysfunctions including abnormalities of cardiac and respiratory control and micturition

Anatomy and physiology

Clinical autonomic and cardiorespiratory abnormalities

4 Diagnosis

Method of clinical diagnosis

The sequential steps in diagnosis

The inductive method: sequential hypothesis generation and testing

Pattern matching

Diagnosis of the and questions should proceed concurrently

Mimicking a computer

The frequency of various findings in the New England Medical Center Posterior Circulation Registry (NEMC-PCR)

Frequency of the location of infarcts within the posterior circulation territories generally and according to stroke mechanisms and arterial lesions

Frequency of symptoms and signs according to posterior circulation territories

Frequency of risk factors according to the presence and location of occlusive vascular lesions

Common patterns of ischemia/infarction

Patterns within the proximal intracranial posterior circulation territory

Patterns within the middle intracranial posterior circulation territory

Patterns within the distal intracranial posterior circulation territory

Diagnosis in the emergency room

Investigations

Brain imaging

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Vascular imaging and functional testing

Ultrasound

Magnetic resonance angiography (MRA)

CT angiography (CTA)

Catheter digital subtraction angiography

Multimodal MRI and CT including perfusion imaging

Blood tests

Evaluation of the heart and aorta

Brainstem reflexes and electrophysiological techniques

Question-driven imaging and laboratory evaluation

5 Treatment

Introduction

Acute ischemic stroke

Maximizing blood flow

Controlling position and activity

Managing blood pressure, blood volume, and cardiac output

Reperfusion strategies

Thrombolysis

Intravenous thrombolysis

Intra-arterial thrombolysis

Bridging thrombolytic treatment

Mechanical devices to remove clot

Stroke prevention

Surgery

Angioplasty and stenting

Surgically bypassing regions of blockage

Prevention of clot formation, propagation, and embolism

Clot formation and pathophysiology

Anticoagulants

Antiplatelet agents

Theoretical utility of the various antithrombotic agents

Trials of antithrombotic agents that include data regarding posterior circulation vascular lesions

Section II Posterior Circulation Ischemia: Specific Vascular Sites and Conditions

6 Extracranial occlusive disease

The development of ideas and information

Subclavian artery occlusive disease

The subclavian steal syndrome

Proximal vertebral artery occlusive disease

Causes, frequency, and epidemiology of arterial lesions at various neck sites

Frequencies and demography

Etiologies

Subclavian artery

Innominate artery

Vertebral arteries

The V segment

Dissections: V and V segments

Neck positioning and cervical manipulation

Cervical vertebral traumatic fractures

Cranio-Cervical junction bone and joint lesions

Cervical spondylitis

Symptoms, signs, and stroke mechanisms

Innominate artery

Subclavian artery

Proximal vertebral artery lesions

NEMC Posterior Circulation Registry (NEMC-PCR) findings: proximal V portion

Dissections of the V and V portions of the vertebral artery in the neck

Diagnostic evaluation

Physical examination of the supplying arteries and the upper limbs

Ultrasound

Vascular imaging: CTA and MRA, and catheter angiography

Treatment

Medical treatment

Atherosclerotic occlusive disease of the proximal vertebral arteries

Cervical vertebral artery dissections

Surgical treatment

Innominate and subclavian arteries

Proximal portion of the vertebral artery

Angioplasty and stenting

Innominate and subclavian arteries

Vertebral artery disease

Summary of present state of therapy

7 Intracranial vertebral arteries and the proximal intracranial territory

Background and development of ideas

Lateral medullary infarction

Hemimedullary and medial medullary infarction

Cerebellar infarction in PICA territory

ICVA disease

Atherosclerosis

Embolism to and from the ICVA

Dissections of the ICVA

Dolichoectasia (dilatative arteriopathy)

Clinical findings in patients with proximal posterior circulation intracranial territory infarcts

Lateral medullary infarcts

Medial medullary infarcts

Cerebellar infarction in PICA distribution

Findings in the New England Medical Center Posterior Circulation Registry

ICVA vascular lesions

Group A. Focal hypoperfusion-related TIAs or infarcts limited to the proximal territory

Group B. Embolism to the ICVA

Group C. ICVA/BA junction disease with middle territory infarction

Group D. Widespread posterior circulation occlusive disease with multifocal hypoperfusion

Group E. Distal territory infarcts due to intra-arterial embolism or hypoperfusion

Outcomes

Proximal intracranial posterior circulation territory infarcts

Conclusions from NEMC-PCR data

Diagnosis and treatment

Diagnosis

Treatment

Antithrombotic treatment

Thrombolysis with or without mechanical devices

Surgical and angioplasty/stenting for stroke prevention

8 Basilar artery

Development of ideas

Early clinico-anatomical necropsy-based reports of basilar artery occlusion

Kubik and Adams’s classical report on the pathology and syndrome of basilar artery occlusion and subsequent series of cases

Transient prodromal symptoms: “vertebrobasilar insufficiency” and its management with anticoagulants

“Top-of-the-basilar” embolism

Improved brain and vascular imaging allowed safer and more rapid clinical diagnosis

Posterior circulation stroke registries

Pathology, pathophysiology, and frequency of vascular lesions

Atherosclerosis

Embolism

Dissection

Aneurysms and dilatative arteriopathy

Other, less common causes

Symptoms and signs

Pontine ischemia and the middle posterior circulation intracranial territory

Motor symptoms and signs

Oculomotor and pupillary signs

Conjugate horizontal gaze and sixth nerve palsies

Internuclear ophthalmoplegia (INO)

One-and-a-half syndrome

Ocular bobbing

Nystagmus

Ptosis

Skew deviation

Pupillary abnormalities

Sensory abnormalities

Coma and reduced level of consciousness

Upper brainstem ischemia as part of the “top-of-the-basilar” syndrome

Oculomotor abnormalities

Pupillary abnormalities

Abnormalities of alertness and behavior

Memory loss and abulia

Other neurological signs

Reports of outcomes in patients with basilar artery disease before the NEMC-PCR and the BASICS studies

Basilar artery lesions in the NEMC Posterior Circulation Registry

Summary conclusions from NEMC posterior circulation data

The Basilar Artery International Cooperative Study (BASICS) registry

Clinical and laboratory diagnosis

Treatment

Reperfusion after acute basilar artery occlusion

Opening the occluded artery

Maximizing blood flow to the ischemic areas

Antithrombotic treatment

Patients with brainstem and cerebellar ischemia who have an acute basilar artery occlusion

Other patients with basilar artery lesions

Anticoagulants and antiplatelet agents

Angioplasty and stenting

9 Posterior cerebral arteries

Background and development of ideas

Occipital lobe anatomy and physiology

Anatomy of the cerebral arterial supply

Clinical studies

Before Foix: late nineteenth and early twentieth century, including Dejerine

Charles Foix

Clinical reports after Foix

Bilateral PCA territory ischemia due to vertebral basilar disease

Clinical, pathological, and neuroradiological studies of the mechanisms of unilateral PCA territory infarcts and their clinical findings

Signs and symptoms of PCA territory infarction correlated with brain and vascular imaging

Pathology and frequency of vascular lesions and stroke mechanisms

Clinical symptoms and signs

Unilateral PCA stenosis and occlusion

Headache

Visual symptoms and findings

Sensory symptoms and findings

Motor dysfunction

Left cerebral hemispheral PCA territory infarction

Right PCA territory cerebral hemispheral infarction

Bilateral PCA territory infarcts

Bilateral inferior calcarine bank temporooccipital ischemia

Bilateral upper calcarine bank parietooccipital lesions

Frequency of various symptoms and signs

PCA and PCA territory vascular lesions in the New England Medical Center Posterior Circulation Registry

Distribution and location of infarctions

Stroke mechanisms

Cardiac-source embolism group ( = 32)

Intra-arterial embolism group ( = 25)

Uncertain embolism source group ( = 8)

Intrinsic PCA occlusive disease ( = 7)

Vasoconstriction ( = 4)

Coagulopathy ( = 3)

Summary and conclusions from the NEMC data

Diagnosis

Treatment

10 Penetrating arteries

Development of ideas about the pathology that causes small deep infarcts

Lacunes

Intracranial branch atheromatous disease

Development of knowledge about the anatomy of posterior circulation branches

Signs, symptoms, and syndromes in penetrating branch artery disease at various brainstem sites

Medulla oblongata

Medial and paramedian medullary infarcts

Lateral medullary infarction

Pons

Anteromedial infarcts

Pure motor hemiplegia (PMH)

Ataxic hemiparesis

Dysarthria–clumsy hand syndrome

“Pure sensory stroke”

Anterolateral infarcts

Lateral tegmental infarcts

Pontine tegmental infarcts of uncertain cause

Midbrain

Midbrain infarcts with predominant oculomotor abnormalities

Midbrain infarcts with prominent motor and/or ataxic abnormalities

Midbrain infarcts with predominant sensory abnormalities

Thalamus

Vascular supply regions

Lateral thalamic infarcts

Pure sensory stroke

Lateral thalamic infarcts (the Dejerine-Roussy syndrome)

Sensorimotor stroke

Polar artery territory infarction

Thalamic–subthalamic artery territory infarcts

Posterior choroidal artery territory infarction

Other thalamic infarcts

The New England Medical Center Posterior Circulation Registry experience

Diagnosis

Treatment of patients with branch artery occlusive disease

11 Cerebellar infarcts

Essential cerebellar brain and vascular anatomy and physiology

Brain anatomy and functions

Vascular anatomy

Development of ideas about cerebellar lesions and infarcts

Cerebellar infarcts: distribution, general clinical signs, outcome, and etiologies

Posterior inferior cerebellar artery (PICA) territory cerebellar infarcts

Anterior inferior cerebellar artery (AICA) territory cerebellar infarcts

Superior cerebellar artery (SCA) territory cerebellar infarcts

Multiple cerebellar artery territory infarcts

Small, nonterritorial cerebellar infarcts

Pseudotumoral space-occupying cerebellar infarcts

Hemorrhagic cerebellar infarcts

Concluding comments

12 Migraine

Background information about migraine

Migraine “auras” and accompaniments

Basilar artery migraine

Vascular and hematological abnormalities

Migrainelike conditions

Reversible cerebral vasoconstriction syndrome

Bartleson syndrome

Strokelike migraine attacks after radiation therapy

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephaly

Differentiation of migrainous accompaniments from atherostenosis-related brain ischemia

“Migrainous strokes”

Summary and conclusions

13 Venous and dural sinus thrombosis

Anatomy

Development of ideas

Etiologies

Infections

Hormonal factors: pregnancy, postpartum, oral contraceptives

Hematological conditions and coagulopathies

Intracranial tumors

Systemic inflammatory conditions

Dural fistulas

Idiopathic (cause not identified)

Distribution of the venous structures involved

General clinical features

Demography

Mode of onset

Headache

Seizures

Decreased level of consciousness

Focal neurological symptoms/signs and focal brain imaging lesions

Outcomes

Thrombosis of venous structures that drain the structures within the posterior circulation

Lateral sinus thrombosis

Deep vein occlusions

Cortical and cerebellar vein occlusions

Diagnosis

Clinical

D-dimer measurements

Computed tomography

Magnetic resonance imaging

Transcranial Doppler

Treatment

Section III Posterior Circulation Hemorrhage

References

14 Parenchymatous hemorrhage

General considerations

Causes

Hypertension

Trauma

Bleeding diatheses

Cerebral amyloid angiopathy

Other causes

Growth of hematomas

Clinical course and general symptoms and signs

Clinical course

Headache

Decrease in the level of alertness

Vomiting

Other general findings

Historical background

Hemorrhages at various posterior circulation sites

Pontine hemorrhages

Large, middle of the pons, hematomas

Unilateral basal or tegmental small hematomas

Lateral pontine tegmental hematomas

Secondary pontine hematomas

Cerebellar hemorrhages

Thalamic hemorrhages

Ventrolateral (posterolateral) thalamic hematomas

Posteromedial thalamic hematomas

Small anterolateral, posterodorsal, medial, and ventrolateral thalamic hematomas

Midbrain hemorrhages

Medullary hemorrhages

15 Subarachnoid hemorrhage, aneurysms, and vascular malformations

Subarachnoid hemorrhage and intracranial aneurysms

Development of ideas

Distribution of posterior circulation aneurysms and SAH

Clinical findings

Clinical and imaging diagnosis

Treatment

Vascular malformations

Development of ideas

Types and locations of malformations

Cavernous angiomas

Diagnosis

Treatment

Developmental venous anomalies

Treatment

Telangiectasias

Arteriovenous malformations

Diagnosis

Treatment

Dural arteriovenous fistulas

Diagnosis

Prognosis and treatment

Index

 

An aparitie	2 April 2015
Autor	Louis R. Caplan
Dimensiuni	22.23 x 3.81 x 27.94 cm
Editura	Cambridge University Press
Format	Hardcover
ISBN	9780521763066
Limba	Engleza
Nr pag	608