Neurology -- Correspondence for Passero and Rossi, 70 (1) 66-72

Correspondence published:

Natural history of vertebrobasilar dolichoectasia: Sevda Sarikaya, Basar Sarikaya (12 March 2008)

Reply from the authors: Stefano G. Passero (12 March 2008)

Natural history of vertebrobasilar dolichoectasia 12 March 2008

Sevda Sarikaya,
Neurology Department, Gaziosmanpasa University School of Medicine
Gaziosmanpasa University Hospitals, 60100 Tokat, Turkey,
Basar Sarikaya
Send Correspondence to journal:
Re: Natural history of vertebrobasilar dolichoectasia

sevdasarikayamd{at}yahoo.com Sevda Sarikaya, et al.

We read the article by Passero and Rossi with great interest. [1] This is one of the most comprehensive and compact reviews of vertebrobasilar dolichoectasia in the literature and covers all the aspects of the disease with focus on the ischemic side.
The authors discuss the high rate of ischemic stroke and possible mechanisms, noting that not all the patients may benefit from anti-platelet or anti-coagulant therapy which puts them at risk for intracranial hemorrhage. [2] We want to emphasize something that the authors did not mention which is the presence of thrombus in the dilated arteries either isolated or along with dissection. There are a few case reports, mostly involving imaging. [3-5]
We would like to present a 50–year-old man with recurrent posterior system ischemic attacks and with typical dolichoectatic disease who had thrombus in the dilated left intradural vertebral artery. He was put on oral anti-coagulation and become free of any attacks during the follow-up period. Imaging studies after 6 months indicated the complete disappearance of the thrombus and newly formed calcific changes were seen at the site of the thrombus. After six months of oral anti-coagulation therapy, the patient was switched to anti-aggregant therapy and has remained symptom-free.
We believe that the presence of thrombus in the dolichoectatic vessels significantly weighs towards anti-coagulant use despite the possibility of intracranial hemorrhage which may otherwise be more hazardous. We found it worthy to present the excellent short-term result obtained in our patient.
However, we emphasize the need for thorough long term follow-up with imaging, especially for the possibility of thrombus recurrence.
References
1. Passero SG, Rossi S. Natural history of vertebrobasilar dolichoectasia. Neurology. 2008;70:66-72.
2. Kumral E, Kisabay A, Ataç C, Kaya C, Calli C. The mechanism of ischemic stroke in patients with dolichoectatic basilar artery. Eur J Neurol 2005; 12:437-444.
3. Vieco PT, Maurin EE 3rd, Gross CE. Vertebrobasilar dolichoectasia: evaluation with CT angiography. AJNR Am J Neuroradiol 1997; 18:1385-1388.
4. De Georgia M, Belden J, Pao L, Pessin M, Kwan E, Caplan L. Thrombus in vertebrobasilar dolichoectatic artery treated with intravenous urokinase. Cerebrovasc Dis 1999; 9:28-33.
5. Büttner U, Ott M, Helmchen C, Yousry T. Bilateral loss of eighth nerve function as the only clinical sign of vertebrobasilar dolichoectasia. J Vestib Res 1995; 5:47-51.
Disclosure: The authors report no conflicts of interest.

Reply from the authors 12 March 2008

Stefano G. Passero,
University of Siena. Detp. of Neurosciences
viale Bracci 53100 Siena Italy
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Re: Reply from the authors

passero{at}unisi.it Stefano G. Passero

We thank Drs. Sarikaya and Sarikaya for their interest in our article. Our methodology took into account the impact of superimposed atherosclerotic changes on the occurrence of ischemic cerebrovascular events. To this end, each patient was scored for the severity of atherosclerotic changes in the posterior and anterior circulation.
Thrombosis of posterior circulation vessels was an infrequent finding and only two patients out of 156 had this condition. In patients with vertebrobasilar dolichoectasia, atherosclerotic changes of the posterior circulation may contribute to cerebral ischemia. However, our multivariate analysis showed that the presence of superimposed atherosclerotic changes of the posterior circulation was not significantly associated with the occurrence of ischemic stroke, suggesting that mechanisms other than atherosclerosis are involved.
In our statistical analysis, we did not separately analyze the patients that were treated with anti-coagulant agents because of the small number. After initial stroke, six patients were treated with anti-coagulants. Of these, five had recurrent stroke (two ischemic and three hemorrhagic) and one had a new asymptomatic ischemic lesion. Three patients died from recurrent stroke.
It is possible that treatment with anti-coagulants in specific situations such as that reported by Sarikaya and Sarikaya may lead to excellent short-term results. However, our results suggest that in patients with vertebrobasilar dolichoectasia, the treatment with anti-coagulant agents is not as effective as expected in preventing recurrent ischemic cerebrovascular events. Furthermore, the long-term prognosis of these patients is worsened by the occurrence of intracranial bleedings.
Disclosure: The authors report no conflicts of interest