Intracranial artery stenosis, Mayfield Brain & Spine, Cincinnati, Ohio

Overview

Intracranial stenosis is a narrowing of an artery inside the brain. A buildup of plaque (atherosclerosis) inside the artery wall reduces blood flow to the brain. Atherosclerosis that is severe enough to cause symptoms carries a high risk of stroke and can lead to brain damage and death. Treatments aim to reduce the risk of stroke by controlling or removing plaque buildup and by preventing blood clots.

Blood supply of the brain

To understand arterial stenosis, it is helpful to know how blood circulates to the brain (see Anatomy of the Brain). Blood is pumped from the heart and carried to the brain by two paired arteries, the internal carotid arteries and the vertebral arteries (Fig. 1). The internal carotid arteries supply the anterior (front) areas and the vertebral arteries supply the posterior (back) areas of the brain. After passing through the skull, the right and left vertebral arteries join together to form a single basilar artery. The basilar artery and the internal carotid arteries communicate with each other in a ring at the base of the brain called the Circle of Willis. The arteries most likely to be affected by stenosis are the internal carotid artery (ICA), the middle cerebral artery (MCA), the vertebral arteries, and the basilar artery. 

Figure 1. Intracranial stenosis is the narrowing of an artery inside the brain due to buildup of plaque inside the artery. The arteries most likely to be affected by stenosis are the internal carotid artery, the middle cerebral artery, the vertebral arteries, and the basilar artery.

What is intracranial artery stenosis?

Intracranial stenosis is a narrowing of the arteries inside the brain. Similar to carotid stenosis in the neck, it is caused by a buildup of plaque in the inner wall of the blood vessels. This narrowing of the blood vessels causes decreased blood flow to the area of the brain that the affected vessels supply. There are three ways in which intracranial artery stenosis can result in a stroke:

1. Plaque can grow larger and larger, severely narrowing the artery and reducing blood flow to the brain. Plaque can eventually completely block (occlude) the artery.
2. Plaque can roughen and deform the artery wall, causing blood clots to form and blocking blood flow to the brain.
3. Plaque can rupture and break away, traveling downstream to lodge in a smaller artery and blocking blood flow to the brain.

What are the symptoms?

The symptoms of intracranial artery stenosis are a transient ischemic attack (TIA) or stroke, which can be described with the mnemonic FAST:

F: for facial weakness or droop, especially on one side
A: for arm or leg weakness, tingling, or numbness, especially on one side
S: for slurred speech
T: for time. If you or a loved one develops these symptoms, it is time to call 911 immediately.

Symptoms of a TIA and stroke are similar. TIAs result when blood flow to the brain is temporarily interrupted and then restored. The symptoms typically last a couple of minutes and then resolve completely, and the person returns to normal. However, TIAs should not be ignored; they are a warning that an ischemic stroke and permanent brain injury may be looming. If you or a loved one develops these symptoms, you should call 911 immediately.

What are the causes?

Atherosclerosis is a major cause of intracranial artery stenosis. It can begin in early adulthood, but symptoms may not appear for several decades. Some people have rapidly progressing atherosclerosis during their thirties, others during their fifties or sixties. Atherosclerosis begins with damage to the inner wall of the artery caused by high blood pressure, diabetes, smoking, and elevated “bad” cholesterol. Other risk factors include obesity, heart disease, family history, and advanced age.

Intracranial stenosis is associated with several conditions, including moyamoya disease, radiation-induced vessel damage (vasculopathy), high blood pressure, high cholesterol, and diabetes.

Who is affected?

Intracranial stenosis is responsible for 8 to 10% of strokes in the United States and affects certain ethnic groups more than others. These groups include African Americans, Asian Americans, and Hispanics. Patients with intracranial artery disease tend to be younger than those with carotid artery disease in the neck.

How is a diagnosis made?

The doctor will learn as much as possible about your symptoms, current and previous medical problems, current medications, and family history. He or she will perform a physical exam. One or more diagnostic imaging tests will be performed to detect narrowing of the intracranial arteries:

• Computed Tomography Angiography, or CT angiogram, is a noninvasive X-ray that provides detailed images of anatomical structures within the brain. It involves injecting a contrast agent into the blood stream so that arteries of the brain can be seen. This type of test provides the best pictures of both blood vessels (through angiography) and soft tissues (through CT). It enables doctors to see the narrowed artery and to determine how much it has narrowed.
• Magnetic Resonance Angiography (MRA) is similar to the CT angiogram. Contrast dye is injected through an IV to illuminate blood vessels in the neck.
• Angiogram is a minimally invasive test that uses X-rays and a contrast agent injected into the arteries through a catheter in the groin. It enables doctors to visualize all arteries and veins in the brain. It carries a low risk of permanent neurologic complications. Beyond identifying the area of disease, angiography provides valuable information about the degree of stenosis and shape of the plaque (Fig 2).

Figure 2. Angiogram shows a narrowing of the middle cerebral artery (red arrows) caused by atherosclerotic plaque.

• Transcranial Doppler Ultrasound is a quick, inexpensive test used to measure the velocity of blood flow through blood vessels in the brain. Technicians measure blood flow velocity by emitting a high-pitched sound wave from an ultrasound probe. Different speeds of blood flow appear in different colors on a computer screen. The more sluggish the blood flow, the greater the risk of stroke.
• Computed Tomography (CT) Perfusion imaging is a noninvasive test that detects blood flow in the brain and is used in planning surgery. It involves injecting a contrast agent into the bloodstream so that doctors 1) can study how much blood flow is reaching the brain and 2) can determine which areas of the brain are most at risk of stroke. During the test a medication called Diamox (acetazolamide) is given to dilate the arteries. This medication is a type of “stress test” for the brain and is similar to a stress test used for the heart.
• Positron Emission Tomography (PET) allows the doctor to study the brain’s function by observing how glucose (sugar) is metabolized in the brain. A small amount of radioactive glucose is injected into the bloodstream. The PET scanner takes pictures of the brain that are interpreted by a computer. The results may help doctors locate abnormalities.

What treatments are available?

The goal of treatment is to reduce the risk of stroke. Treatment options for intracranial stenosis vary according to the severity of the narrowing and whether you are experiencing stroke-like symptoms or not. Patients are first treated with medication and are encouraged to make lifestyle changes to reduce their risk of stroke. Surgery is limited to patients whose symptoms do not respond to medication. 

Medications
Intracranial stenosis can be treated with medications that minimize risk factors, including high cholesterol and blood pressure. If you smoke, you may be prescribed medications that help you quit. Patients with diabetes will be advised to maintain tight control of their blood sugar through a healthful diet and careful monitoring.

• Blood thinner medications, also called anticoagulants (aspirin, Plavix, Coumadin), allow the blood to pass through the narrowed arteries more easily and prevent clotting. Studies show that aspirin and Coumadin provide similar benefits. Because blood-thinners are associated with an increased risk of bleeding, patients may be monitored for abnormal bleeding. Aspirin has fewer side effects than Coumadin and is associated with a lower risk of bleeding or hemorrhage [1]. Patients taking Coumadin must have their blood monitored periodically; patients taking aspirin and/or Plavix do not require monitoring.
• Cholesterol-lowering medications help reduce additional plaque formation in atherosclerosis. These medications can reduce LDL (low-density lipoprotein) cholesterol by an average of 25 to 30% when combined with a low-fat, low-cholesterol diet.
• Blood pressure medications (diuretics, ACE inhibitors, angiotensin blockers, beta blockers, calcium channel blockers, etc. ) help control and regulate blood pressure. Because high blood pressure is a major risk factor of stroke, regular blood pressure screenings are recommended, along with taking your medication regularly.

Surgery
The aim of surgery is to prevent stroke by removing or reducing the plaque buildup and enlarging the artery to allow more blood flow to the brain. Surgical treatment is considered for patients whose symptoms do not respond to medication. For example, those who continue to have TIAs or strokes, those with a high grade of stenosis, and those with insufficient blood supply to an area of the brain.

• Balloon angioplasty / stenting is a minimally invasive endovascular procedure that compresses the plaque and widens the diameter of the artery (Fig. 3). Endovascular means that the procedure is performed inside the artery, from within the bloodstream, with a small flexible catheter. The catheter is inserted into the femoral artery in the groin during an angiogram. The catheter is then advanced through the bloodstream to where the plaque-narrowed artery is located. A small balloon is then slowly inflated within the narrowed artery to dilate it and compress the plaque against the artery wall. Figure 3. During angioplasty a balloon-tipped catheter is placed within the narrowed vessel. The balloon is inflated compressing the plaque and opening the artery. After the balloon is removed, a self-expanding mesh-like tube called a stent is placed over the plaque to hold open the artery. The stent remains in the artery permanently.

  The aim is to reduce stenosis by less than 50%, as a small increase of the vessel diameter results in large increases in blood flow to the brain. The balloon is then deflated and removed. In some cases, a self-expanding mesh-like tube called a stent is placed over the plaque, holding open the artery. Complications from angioplasty can include stroke, tearing of the vessel wall from the catheter or balloon, and vasospasm.

  Angioplasty is typically recommended for patients who have high-grade artery stenosis (greater than 70%) and recurrent TIA or stroke symptoms despite medication treatment [2]. Angioplasty / stenting can successful reduce the stenosis to less than 30% without complications in 60 to 80% of patients [3].

• Cerebral artery bypass is a surgical procedure that reroutes the blood supply around the plaque-blocked area. This procedure requires making an opening in the skull, called a craniotomy. A donor artery from the scalp is detached from its normal position on one end, redirected to the inside of the skull, and connected to an artery on the surface of the brain. The scalp artery now supplies blood to the brain and bypasses the blocked vessel (see Cerebral Bypass Surgery). Complications from bypass can include stroke, vasospasm, and clotting in the donor vessel.

  Bypass is typically recommended when the artery is 100% blocked and angioplasty is not possible. Results of artery bypass vary widely depending on the location and type of bypass. Ask your surgeon what results you can expect.

Clinical trials
Clinical trials are research studies in which new treatments—drugs, diagnostics, procedures, and other therapies—are tested in people to see if they are safe and effective. Research is always being conducted to improve the standard of medical care. Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. Studies can be sponsored by the National Institutes of Health (see Clinicaltrials.gov) as well as private industry and pharmaceutical companies (see Centerwatch.com).

Recovery & prevention

Despite treatment with medications, patients who have had a stroke or TIA due to intracranial artery stenosis face a 12 to 14% risk of recurrent stroke during the 2-year period after the initial stroke. In some high-risk groups, the annual risk of recurrent stroke may exceed 20% [4].

After angioplasty, restenosis can occur in 7.5 to 32.4% of patients and is usually not symptomatic. The long-term outcome of stroke prevention after angioplasty is not yet known, but short-term results are promising and is currently being studied in clinical trials.

It’s important to understand that atherosclerosis is a progressive disease. To prevent a stroke, your physician may ask you to stop smoking, limit heavy alcohol consumption, maintain good blood-sugar control (if you have diabetes), lower your cholesterol, and take medications as prescribed.

Sources &
links

If you have more questions, please contact Mayfield Brain & Spine at 800-325-7787 or 513-221-1100.

Sources

1. Chimowitz MI, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 352(13):1305-16, 2005
2. Meyers PM, et al.: Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement. Circulation 119:2235–2249, 2009
3. Ringer AJ, Abruzzo T, et al. Angioplasty and Stenting for Management of Intracranial Stenosis. In, Hemorrhagic and Ischemic Stroke: Surgical, Interventional, Imaging, and Medical Approaches. New York, Thieme, 2010
4. Qureshi AI, et al. Consensus conference on intracranial atherosclerotic disease: rationale, methodology, and results. J Neuroimaging 19 Suppl 1:1S-10S, 2009.

Links
StrokeAssociation.org

Stroke.org

angioplasty: an endovascular procedure with a balloon-tipped catheter to enlarge a narrowing in an artery.

atherosclerosis: a disease of the arterial blood vessels, in which the walls of the arteries become thickened and hardened by plaques. Plaques are composed of cholesterol and other lipids, inflammatory cells, and calcium deposits; also called “hardening of the arteries.”

ischemic stroke: a stroke caused by an interruption or blockage of oxygen-rich blood flow to an area of the brain; caused by a blood clot, atherosclerosis, vasospasm, or reduced blood pressure.

LDL cholesterol: Low-density lipoprotein cholesterol is the primary cholesterol molecule. High levels of LDL, nicknamed “bad” cholesterol, increase the risk of atherosclerosis.

stent: a tube-like device that is inserted into a vessel or passageway to keep it open.

transient ischemic attack (TIA): a “mini” stroke caused when blood flow to the brain is temporarily interrupted and then restored; causes no permanent brain damage.

vasospasm: abnormal narrowing or constriction of arteries due to irritation of the vessel wall or by blood in the subarachnoid space.

updated > 4.2018
reviewed by > Andrew Ringer, MD, Mayfield Clinic, Cincinnati, Ohio

Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic. We comply with the HONcode standard for trustworthy health information. This information is not intended to replace the medical advice of your health care provider.

Blood Vessel Conditions: How an Angiogram Can Help Your Diagnosis | Blog

As your heart beats, it pumps blood through your circulatory system. It is made up of blood vessels that are similar to elastic tubes. They are responsible for carrying blood to every part of your body.

Vascular disease is any condition affecting your circulatory system, including diseases of your arteries, lymph vessels, and veins. It also includes any blood disorder that may affect circulation. These conditions are typically diagnosed with an angiogram.

What Is an Angiogram?

The simple answer to what is an angiogram is that it is an x-ray of your blood vessels. Since this can be done for many different organs, the angiogram procedure is oftentimes used to help a doctor diagnose a condition that affects your brain, heart, arms, or legs. With this test, your doctor can detect any abnormalities in your blood vessels, including blood clots, weakened blood vessels, and deposits of plaque.

The reason the term “angiogram” is so broad is that it refers to numerous types of diagnostic tests that your doctor may use to detect if there’s a blockage or narrowing of your blood vessels. This is an important test because it is used in diagnosing various cardiovascular diseases such as vascular stenosis, coronary atherosclerosis, and even aneurysms. 

There are several times when a doctor may order this diagnostic test, including:

• If you have abnormal stress test results, this test may be used as a follow up to see if you have signs of a blocked or narrow artery.
• When you’re experiencing new or unusual chest pain, this test may be ordered to find out the cause.
• Anyone who’s had a stroke, heart attack, or suffered from heart failure will typically be given this test.

An angiogram can be used to examine blood vessels throughout the body. This includes those that are located in the heart, chest, back, neck, abdomen, pelvis, arms, hands, legs, and feet.

What Is the Angiogram Procedure?

Traditionally, when your doctor performs this test, they will insert a catheter (a long, narrow tube) into an artery located in the arm, upper thigh, or groin. Contrast dye is then inserted into the catheter so that the doctor can take x-rays of the blood vessels. This dye helps to ensure that the blood vessels are more visible in the x-rays. Today, some doctors no longer use x-ray machines, opting instead for the use of CT scans or MRI scans. 

Once the procedure is completed. It is used to diagnose a variety of conditions, including:

• Aneurysms, a bulge that develops in artery walls when they become weakened
• Atherosclerosis, a condition that occurs when plaques or other fatty materials collect on the inner walls of the arteries
• Pulmonary embolisms, a.k.a. blood clots
• Vascular stenosis, a condition that causes abnormal narrowing in the blood vessels that lead to the brain, legs, or heart
• Congenital abnormalities that may occur in either the blood vessels or heart
• As a way of evaluating the blood vessels’ health before surgery
• To identify any blood vessels that may be feeding a tumor
• To plan treatments such as chemoembolization, coronary bypass, or stenting
• To evaluate how a stent is doing once it’s been placed in the body

Where Should I Get an Angiogram?

There are many reasons why your doctor may suggest that you have this test. If you live in or around the Southern San Joaquin Valley, there’s only one place you should turn to for the procedure. Call (559) 625-4118 or visit South Valley Vascular to talk to a doctor today.

Symptoms of vasoconstriction of the brain. Causes, treatment.

Symptoms of vasoconstriction of the brain. Causes, treatment.

Gimranov Rinat Fazylzhanovich
Neurologist, neurophysiologist, experience – 33 years;
Professor of Neurology, MD;
Clinic for Rehabilitation Neurology. About the author

Publication date: December 8, 2020

Updated: October 25, 2022

Vasoconstriction of the brain and neck is unfortunately too common, and causes diseases with a variety of symptoms and signs, requires treatment that based on the causes of such a state.

At the initial stages, the problem is mild. A person writes off the signs of chronic fatigue. But with the progression of cerebral stenosis, the symptoms will increase. They will eventually lead to severe encephalopathy, dementia, disability or sudden death.

Understanding what threatens the narrowing of the blood vessels of the brain, what it means for later life, you need to know what to do if the diagnosis has already been made.

Moreover, many cases of cerebral vasoconstriction are reversible [1].

The treatment of such patients is carried out throughout life, since it is almost impossible to eliminate the problem and its consequences.

Article content:

• 1 Causes
• 2 Symptoms
• 3 Diagnosis
• 4 Treatment and prognosis
  • 4.1 Medical approach
  • 4 .2 Surgical options
• 5 References

Causes

Problems more often occur in adults, even the elderly. However, young men and women with chronic diseases or leading an unhealthy lifestyle are not immune from the development of stenosis.

It is important for a doctor to understand why the vessels of the brain narrow, what causes it. Indeed, based on the reasons for the decrease in the lumen of arteries and veins, treatment is selected.

Typical reasons for such a pathology:

1. fatty foods, fast food, excessive fondness for sweets;
2. deterioration of flexibility, stiffness of the wall of the arteries of the neck and brain;
3. genetic predisposition;
4. abnormal structure of the vertebral artery;
5. type 2 diabetes;
6. obesity, metabolic syndrome;

1. alcohol abuse;
2. smoking of tobacco and smoking mixtures;
3. life in conditions of hypodynamia;
4. injuries to the head, neck, upper chest [2].

Due to changes in the blood vessels that feed the brain, atherosclerosis, aneurysms, hypertensive conditions and vegetative dystonia develop.

Most of the problems arise from the wrong, sedentary lifestyle that is characteristic of modern city dwellers. Therefore, it is worth monitoring your condition, starting from a young age, in order to notice the first degenerative phenomena in time.

Symptoms

The development of the disease occurs in stages, as the blood flow and oxygen delivered to the brain tissues deteriorate.

Initially, the symptoms are mild and disguised as harmless minimal brain dysfunction. But over time, they lead to a change in personality, the loss of the ability to independently serve oneself, death.

Symptoms of problems with cerebral veins and arteries are:

1. At an early stage, the ability to memorize and assimilate new information weakens. A person often changes his mood, in the evening his head hurts. There are problems with sleep, haunted by a feeling of fatigue.

1. 2 degree is characterized by a decrease in intellectual abilities and memory. There are problems with the processes for which the NCC is responsible. Visual acuity decreases, speech worsens [3]. Headaches become constant. The character changes a lot, the person becomes more infantile, at the same time irritable and even aggressive.

1. 3rd degree – critical. Excessive constriction leads to a serious lack of oxygen. A person is not able to serve himself without outside help. Falls into dementia, loses the ability to control the process of urination and defecation.

Even mild symptoms of narrow vessels of the brain, often mistaken for severe fatigue, require diagnosis and treatment. This will help to identify a dangerous pathology in advance, to postpone the critical deterioration of the condition for years.

Diagnosis

To determine what to do if the vessels of the brain are narrowed and what treatment to choose for the patient, a detailed diagnosis of symptoms helps to establish a specific disease.

The list of required examinations includes procedures:

• MRI, preferably with vascular contrast. The method characterizes the adequacy of blood flow, the foci in which it is slowed down, the condition of the tissues.
• CT (computed tomography) shows the state of the brain tissue, the extent of damaged areas and the degree of their influence on cognitive abilities.
• Electroencephalography monitors the resulting disturbances in the functions of the brain.

• Rheoencephalography, another method for studying the vasculature of the brain [4]. With the help of a directed electrical impulse, the sites of aneurysms or neoplasms that compress blood vessels are monitored.
• Ultrasound of the vessels of the neck and skull in Doppler mode. Helps to assess blood flow in real time, shows aneurysms, arterial stenosis.

After doctors determine why the blood vessels in the brain narrow, what exactly causes headaches and other symptoms, they will make a diagnosis by identifying a specific disease.

Treatment and prognosis

How to treat cerebral vasoconstriction, the doctor decides, after analyzing the symptoms and signs of stenosis in adult patients, he will receive the results of the studies.

The patient’s main task is to follow the recommendations of doctors so as not to aggravate his situation. At the same time, relatives should be prepared for resistance from the patient. Many do not want to admit the obviousness of the problem.

Complex therapy is used to restore health. The scheme includes drug and non-drug components. In some cases, surgery is required, urgent or planned.

Medical approach

Medications last from several months to years. Some recommendations will have to be followed for life. The main task of pharmacological therapy is to eliminate cholesterol plaques, reduce high blood pressure; for this, the following are used:

• Vasodilators. They reduce the tone of the walls of blood vessels, expand their lumen. This improves blood flow and oxygen supply to organs.

• Statins are medicines that reduce cholesterol synthesis. They help to reduce its content in the blood and gradually destroy plaques, expanding the passages in the arteries.
• Fibrates that slow down the formation of atherosclerotic plaques. They are not prescribed simultaneously with statins, despite the similarity of action.

Depending on the disease and concomitant diagnoses, the doctor prescribes one type of drugs or combines them.

We recommend entrusting the choice of how to cure vasoconstriction of the brain, what to drink at the same time, at the discretion of the doctor, even if you know exactly what your disease is called. Self-selection of remedies can only aggravate the situation, since their impact is individual.

In addition to taking pills regularly, you will need to adjust your lifestyle:

• give up bad habits: smoking cigarettes, drinking alcohol;
• avoid fatty foods;
• limit sweets;
• remove semi-finished products and fast food from the diet;
• more frequent outdoor activities, more movement;
• to do physical exercises, exercise therapy – physiotherapy exercises.

Surgical options

In complex cases, surgical intervention is performed:

• Arterial stenting. The narrowed place of the vessel is expanded due to the introduction of a wire tube-stent there. Blood flows through the stent and the adverse effect of the plaque is leveled.
• Angioplasty, when the aneurysm is surgically repaired, a prosthesis is placed from the patient’s own vein or from an artificial material.

• Endarterectomy – the affected vessel is dissected, and then the inner layer (intima) with plaques that clog the lumen is cleaned from it [5].

Systematic treatment is necessary, even if the disease is at an early stage, given the danger of cerebral vasoconstriction, the consequences of a neglected condition can be severe and sometimes fatal.

References

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Vascular endothelial growth factor inhibitors for neovascular glaucoma

This translation is out of date. Please click here for the latest English version of this review.

What is the purpose of this review?

To compare treatment with and without vascular endothelial growth factor (anti-VEGF) inhibitors in people with neovascular glaucoma (NVG).

Key information

It is unclear whether treatment with anti-VEGF drugs is more beneficial in people with neovascular glaucoma. More research is needed to understand the long-term effects of anti-VEGF drugs versus or in addition to conventional treatment.

What did we learn in this review?

VEGF is a protein made by your body’s cells, and it makes new blood vessels when needed. When cells make too much VEGF, abnormal blood vessels can grow in the eyes. Neovascular glaucoma is a type of glaucoma in which the angle between the iris (the colored part of the eye) and the cornea (the clear front part of the eye) is blocked by new blood vessels growing in the eye, hence the name neovascular. New blood vessels can cause scarring and narrowing, which can eventually lead to complete closure of the angle. This leads to an increase in intraocular pressure, since the fluid in the eye cannot drain normally. In neovascular glaucoma, the eye is often red and painful, and vision is reduced. High intraocular pressure can lead to blindness.

An anti-VEGF drug is a type of drug that blocks VEGF, thus slowing down the growth of blood vessels. It is given by injection into the eye. It can be used at an early stage when conventional treatment may not be possible. Most studies report short-term (typically four to six weeks) benefits of anti-VEGF drugs, but long-term benefits are unclear.

What are the main findings of this review?

We included four studies with a total of 263 participants with neovascular glaucoma. One study failed to evaluate outcomes after the 1st week of treatment. In another study, the results were inaccurate due to study design limitations.

The last two studies showed different results in lowering intraocular pressure; one study showed inconclusive results, and another showed the effectiveness of anti-VEGF drugs. The certainty of the data obtained in these studies was low due to the limitations of the study design and the inconsistency of their results. Therefore, the available data are insufficient to recommend the routine use of anti-VEGF drugs in individuals with neovascular glaucoma.