EN | TR
E-ISSN: 1307-5608
Vertebral Artery Origin Stenosis in Patients with Posterior Circulation Strokes Due to Large Artery Atherosclerosis
PDF
Cite
Share
Request
Research Article
VOLUME: 77 ISSUE: 3
P: 243-247
September 2024

Vertebral Artery Origin Stenosis in Patients with Posterior Circulation Strokes Due to Large Artery Atherosclerosis

J Ankara Univ Fac Med 2024;77(3):243-247
DOI: 10.4274/atfm.galenos.2024.59013
Seyda Erdoğan 1
Turgut Şahin 1
Mine Hayriye Sorgun 1
Tuğra Karaaslan 1
Zerin Özaydın Aksun 1
Eray Yalap 1
Onur Bulut 1
Büşra Ölmez 1
Abdullah Yasir Yılmaz 1
Zehra Yavuz 1
Canan Önder 1
Aygül Nadirova 1
Mustafa Erdoğan 2
Eda Aslanbaba 1
Tehran Allahverdi 1
Canan Togay Işıkay 1
1. Ankara University Faculty of Medicine, Department Neurology, Ankara, Türkiye
2. Ankara University Faculty of Medicine, Department of Biostatistics, Ankara, Türkiye
No information available.
No information available
Received Date: 29.05.2024
Accepted Date: 08.07.2024
Online Date: 10.10.2024
Publish Date: 10.10.2024
PDF
Cite
Share
Request

Abstract

Objectives

The origin of the extracranial vertebral artery (V1 segment) is a common site for large artery atherosclerosis (LAA). The aim of this study was to determine the risk factors, prevalence and prognosis of the patients presented with acute ischemic stroke due to vertebrobasilar atherosclerosis and additional V1 stenosis.

Materials and Methods

We reviewed the charts of 957 patients who were admitted with acute ischemic stroke between the dates January 2011 and May 2017, and selected cases with stroke related to posterior circulation (PC) atherosclerosis. The demographic data, risk factors, National Institutes of Health Stroke Scale (NIHSS) scores at admission, and modified Rankin scores (mRS) in the follow-up period were recorded.

Results

There were 80 (8.36%) patients with acute ischemic stroke in the PC due to LAA. Thirty (37.5%) patients [9 females (30%), mean age 67.4±14.3 years] had V1 stenosis. No between group differences in the history of vascular risk factors and mRS scores during the follow-up period were observed (p>0.05). In logistic regression analysis, the admission NIHSS score was higher in patients with V1 stenosis than others (p=0.022).

Conclusion

In our registry, more than one third of patients with acute PC stroke due to LAA had stenosis in the origin of the vertebral artery. The patients with coexisting V1 stenosis presented with relatively severe stroke.

Introduction

Prognosis and clinical management differ significantly among stroke subgroups according to anatomical localization and infarct mechanism in patients with acute ischemic stroke. One fifth of strokes and transient ischemic attacks (TIA) occur in the posterior circulation (PC) area (1). The most common causes of PC ischemia are large artery atherosclerosis (LAA), cardiac embolism and small vessel occlusion (2, 3).

Anatomically, the vertebral artery is traditionally evaluated in four parts (V1-4). The first segment (V1) is the part from the origin of the vertebral artery to the foramen in the transverse processes of the fifth or sixth cervical vertebra. In the PC, atherosclerosis usually occurs at the origin of the vertebral artery. Autopsy and angiography studies have shown that up to 40% of patients with cardiovascular risk factors have stenosis or occlusion at the origin of the vertebral artery (2-4). Moreover, V1 segment stenosis of the vertebral artery accounts for almost 20% of PC strokes (2).

This study aimed to investigate the prevalence, demographic and clinical characteristics of ischemic stroke patients diagnosed with vertebral artery V1 stenosis due to LAA.

Materials and Methods

The medical records of patients hospitalized with a diagnosis of acute ischemic stroke at the Ankara University Faculty of Medicine Neurology Department between January 2011 and May 2017 were reviewed. Age, gender, drug history, vascular risk factors [hypertension (HT), diabetes mellitus (DM), hyperlipidemia (HL), atrial fibrillation (AF), coronary artery disease (CAD), congestive heart failure (CHF) and malignancy], history of stroke or TIA, history of myocardial infarction in the last month, recurrent stroke status, admission National Institutes of Health Stroke Scale (NIHSS) score, pre-stroke and follow-up modified Rankin scores (mRS), and laboratory results were recorded. The etiologic workup included cerebral and cervical vascular imaging studies [carotid Doppler ultrasonography, computerized tomography angiography, magnetic resonance angiography, or digital subtraction angiography (DSA)], transthoracic or transesophageal echocardiography, 24- hour cardiac rhythm monitoring, and laboratory tests for hypercoagulability and vasculitis. Automated Causative classification of stroke system was used to determine the etiological type of ischemic stroke (5). Patients with acute ischemic stroke in the PC due to LAA (PC infarction-LAA) were included in the study.

The Ankara University Faculty of Medicine Clinical Research Ethics Committee granted ethical approval for this study (date: 27.05.2019, approval no.: 10-772-19) and the study was conducted in accordance with the ethical standards of the Declaration of Helsinki.

Statistical Analysis

The analysis of the data was made in the SPSS for Windows 15 package program. Descriptive statistics are shown as mean ± standard deviation for variables with normal distribution, and as median (minimum-maximum) for variables with non-normal distribution, and nominal variables are shown as number of cases and percentage (%). The significance of the difference between the two groups in terms of means was investigated with the t-test, and the significance of the difference in terms of median values was investigated with the Mann-Whitney U test. Nominal variables were evaluated with Pearson’s chi-square or Fisher’s exact test. Logistic regression analysis was performed for the risk factors affecting the dependent variable. Results for p<0.05 were considered statistically significant.

Results

We reviewed the charts of 957 patients who were admitted with acute ischemic stroke between January 2011 and May 2017. A total of 80 (8.36%) patients had acute ischemic stroke in the PC due to LAA.

Thirty (37.5%) patients [27 females (90%), mean age 67.4±14.3 years] had symptomatic V1 stenosis and 15 (18.75%) patients [13 females (86.7%), mean age 68.2±18.05 years] of them had isolated V1 stenosis.

We compared the patients with acute ischemic stroke in the PC due to LAA with and without V1 stenosis. No between group differences in history of vascular risk factors and mRS in the follow-up period were observed (p>0.05). The admission NIHSS score was higher in patients with V1 stenosis (p=0.049). Serum C-reactive protein (CRP) levels were higher in patients without V1 stenosis, whereas serum magnesium levels were higher in patients with V1 stenosis. The demographic data, clinical and laboratory results are summarized in Table 1.

The distribution of arteries with significant stenosis in the PC is shown in Table 2.

In logistic regression analysis, admission NIHSS scores and serum magnesium levels were still significantly higher in patients with V1 stenosis (p<0.05) (Table 3). The mean admission NIHSS score ± standard deviation in patients with coexisting V1 stenosis was 11.5±11.7, while it was 4.88±4.55 in patients without V1 stenosis (p=0.001). The admission NIHSS score was significantly higher in patients with coexisting V1 stenosis in logistic regression analysis (p=0.018).

Discussion

Various vascular structures belonging to the intra- or extracranial as well as anterior or PC may be affected in ischemic stroke. Etiological, clinical and prognostic features may vary depending on the vascular structures affected by atherosclerotic stenosis (6). Investigating the subtypes of ischemic stroke according to the affected vessel and underlying causes may be beneficial in terms of better understanding the risk factors and clinical features of the disease.

In PC ischemic strokes, there may be different underlying causes, including cardio-embolism, LAA and small vessel disease (7). The rate of large vessel disease as the etiology of PC ischemic strokes varies among studies depending on the diagnostic criteria used and the diagnostic methods performed (8). Large artery disease was responsible for 32% of posterior cerebral artery territory infarcts in the New England Medical Center PC Registry (2).

LAA is defined as >50% stenosis or occlusion of a large cervical or cerebral artery (9). In the PC, atherosclerosis commonly occurs at the origin of the vertebral artery (7). However, atherosclerosis can also occur in the distal vertebral, basilar and posterior cerebral arteries. In this study, we focused on posterior system strokes due to LAA. We investigated whether there were differences in the demographic and clinical characteristics between patients with and without V1 stenosis.

Vertebral artery stenosis (24.8%) ranks second among extracranial stenosis after internal carotid stenosis (59.4%) (10). The rate of V1 stenosis among patients with acute ischemic stroke in the PC due to LAA was 37.5% in our registry. In a prospective cross-sectional study conducted in Iran examining 3703 acute stroke patients, vascular imaging with DSA was performed in 342 patients with large vessel disease, and stenosis was detected in the extracranial segment of the right and/or left vertebral artery in 32% of them (10). The researchers noted that these results were similar to the North American and European data. Similarly, in the Oxford Vascular Study, severe stenosis of the vertebral or basilar artery was responsible for 26% of patients with posterior system minor stroke or TIA (11).

Although male dominance was noted in patients with V1 stenosis (70% vs. 52%), no statistically significant difference was detected between the two groups in terms of age and gender. There was also no group difference in the history of vascular risk factors, including HT, AF, DM and HL as well as history of CAD and CHF. In this study, median admission NIHSS score was higher in patients with V1 stenosis (p=0.049) suggesting that stroke may be clinically more severe in patients with coexisting V1 stenosis. The higher frequency of additional vertebrobasilar stenosis (V2, V3 segment, basilar artery and posterior cerebral artery) in half of the patients with V1 segment stenosis included in the study may be related to the higher severity of stroke and high NIHSS scores in this group.

Signs and symptoms seen in PC infarcts include dizziness, vertigo, dysarthria, diplopia, dysphagia, nausea or vomiting, impaired consciousness, weakness, ataxia and nystagmus (2, 3). However, in our study, we did not analyze which symptoms and findings were responsible for the higher NIHSS scores in patients with V1 stenosis. Although patients with V1 stenosis had a higher admission NIHSS score, there was no difference between the two groups in terms of hospital mortality rates and mRS scores or recurrent strokes at follow-up. In patients without V1 stenosis, presentation with TIA was more common (46% vs. 30%). However, the difference between the two groups in terms of stroke or TIA presentation was not significant.

Interestingly, serum CRP levels were higher and serum magnesium levels were lower in patients without V1 stenosis when compared with patients with V1 stenosis. Both higher CRP and lower magnesium (Mg) levels may be associated with an increased risk for atherosclerosis (12, 13). On the other hand, both may point to poor prognosis in patients with stroke (14-16). A recent study revealed that although admission NIHSS scores were similar between patients with normal and high CRP levels, high CRP levels could predict poor prognosis (15). In our study, the admission NIHSS score was lower in patients without V1 stenosis, even though serum CRP levels were higher and serum magnesium levels were lower. The outcomes were similar in both groups despite these differences.

Conclusion

This study is a retrospective study and included only a small number of patients from a single center; therefore, the results should be interpreted cautiously. However, we can conclude that PC stroke with coexisting V1 stenosis may be associated with stroke severity in the acute stage. The associations between localization of stenosis, stroke severity and serum biomarkers, including CRP and Mg levels need to be further investigated which may help to understand the pathogenesis and choose better prevention and treatment methods.

References

1
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG); Darby S, McGale P, Correa C, Taylor C, Arriagada R, Clarke M, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011; 378: 1707-1716. (PMID: 22019144)
2
Fisher ER, Anderson S, Tan-Chiu E, Fisher B, Eaton L, Wolmark N. Fifteen-year prognostic discriminants for invasive breast carcinoma: National Surgical Adjuvant Breast and Bowel Project Protocol-06. Cancer 2001; 91: 1679-1687. (PMID: 11309768)
3
Veronesi U, Marubini E, Mariani L, Galimberti V, Luini A, Veronesi P, et al. Radiotherapy after breast-conserving surgery in small breast carcinoma: long-term results of a randomized trial. Ann Oncol 2001; 12: 997-1003. (PMID: 11521809)
4
Yashar C, Attai D, Butler E, Einck J, Finkelstein S, Han B, et al. Strut-based accelerated partial breast irradiation: Report of treatment results for 250 consecutive patients at 5 years from a multicenter retrospective study. Brachytherapy 2016; 15: 780-787. (PMID: 27528591)
5
Yoshida M, Yoshimura RI, Notake R, Shinjo H, Miyaura K, Kuwayama T, et al. Feasibility of accelerated partial breast irradiation with strut-adjusted volume implant brachytherapy in Japan focusing on dosimetry and acute toxicity: a Japanese multi-institutional prospective study. Breast Cancer 2024; 31: 75-83. (PMID: 37865624)
6
Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, et al. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14: 112-132. (PMID: 37984712)
7
Vicini FA, Cecchini RS, White JR, Arthur DW, Julian TB, Rabinovitch RA, et al. Long-term primary results of accelerated partial breast irradiation after breast-conserving surgery for early-stage breast cancer: a randomised, phase 3, equivalence trial. Lancet 2019; 394: 2155-2164. (PMID: 31813636)
8
Coles CE, Griffin CL, Kirby AM, Titley J, Agrawal RK, Alhasso A, et al; IMPORT Trialists. Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet 2017; 390: 1048-1060. (PMID: 28779963)
9
Meattini I, Marrazzo L, Saieva C, Desideri I, Scotti V, Simontacchi G, et al. Accelerated Partial-Breast Irradiation Compared With Whole-Breast Irradiation for Early Breast Cancer: Long-Term Results of the Randomized Phase III APBI-IMRT-Florence Trial. J Clin Oncol 2020; 38: 4175-4183. (PMID: 32840419)
10
Benitez PR, Chen PY, Vicini FA, Wallace M, Kestin L, Edmundson G, et al. Partial breast irradiation in breast conserving therapy by way of intersitial brachytherapy. Am J Surg 2004; 188: 355-364. (PMID: 15474426)
11
Whelan TJ, Julian JA, Berrang TS, Kim DH, Germain I, Nichol AM, et al. External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): a randomised controlled trial. Lancet 2019; 394: 2165-2172. (PMID: 31813635)
12
Orecchia R, Veronesi U, Maisonneuve P, Galimberti VE, Lazzari R, Veronesi P, et al. Intraoperative irradiation for early breast cancer (ELIOT): long-term recurrence and survival outcomes from a single-centre, randomised, phase 3 equivalence trial. Lancet Oncol 2021; 22: 597-608. (PMID: 33845035)
13
Murray Brunt A, Haviland JS, Wheatley DA, Sydenham MA, Alhasso A, Bloomfield DJ, et al; FAST-Forward Trial Management Group. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial. Lancet 2020; 395: 1613-1626. (PMID: 32580883)
14
Meattini I, Becherini C, Boersma L, Kaidar-Person O, Marta GN, Montero A, et al. European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice consensus recommendations on patient selection and dose and fractionation for external beam radiotherapy in early breast cancer. Lancet Oncol 2022; 23: e21-e31. (PMID: 34973228)
15
Strnad V, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, et al. 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet 2016; 387: 229-238. (PMID: 26494415)
16
Sato K, Fuchikami H, Takeda N, Shimo T, Kato M, Okawa T. Efficacy of Single-Plane Implant Technique in Partial Breast Brachytherapy in Small-Breasted Patients. Int J Radiat Oncol Biol Phys 2020; 106: 830-837. (PMID: 31785336)
17
Shah C, Badiyan S, Ben Wilkinson J, Vicini F, Beitsch P, Keisch M, et al. Treatment efficacy with accelerated partial breast irradiation (APBI): final analysis of the American Society of Breast Surgeons MammoSite(®) breast brachytherapy registry trial. Ann Surg Oncol 2013; 20: 3279-3285. (PMID: 2397530))