AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2641-0419/117
*Corresponding Author: Damyan B Boychev, Acibadem City Clinic Cardiovascular center, Sofia
Citation: Ivo Petrov, Zoran Stankov, Damyan Boychev, Valentin Balabanski, Marko Klissurski (2021 Basilar Artery Occlusion. Clinical Evaluation and Contemporary Methods of Treatment. J. Clinical Cardiology and Cardiovascular Interventions, 4(1); Doi:10.31579/2641-0419/117
Copyright: © 2021 Damyan B Boychev, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 01 December 2020 | Accepted: 19 December 2020 | Published: 08 January 2021
Keywords: posterior circulation stroke; basilar artery occlusion; intravenous thrombolysis; endovascular treatment
Acute occlusion of the basilar artery and its branches is a frequent cause of posterior circulation strokes. Although it accounts for only 1 to 3 % of ischemic strokes, it is a potentially life-threatening condition associated with high mortality rates. Exact clinical diagnosis is still challenging because symptoms such as vertigo, dizziness followed by headache, and neck pain are nonspecific and usually attributed to many other neurological diseases. The onset of symptoms can be abrupt or gradual and progressive. Establishing the time of symptoms onset and making a timely diagnosis is highly important. In case the diagnosis is made promptly, ideally with the help of an advanced neuroimaging, intravenous thrombolysis, or catheter-based endovascular treatment can be performed immediately to improve prognosis and reduce mortality.
Basilar artery occlusion – BAO
Posterior circulation ischemia – PCI
Intra-arterial thrombolysis – IAT
Intravenous thrombolysis - IVT
Basilar artery – BA
Posterior Circulation – PC
Anterior Circulation – AC
Vertebrobasilar ischemia – VBI
Modified ranking score – mRS
Mechanical thrombectomy - MT
Basilar artery occlusion (BAO) accounts for about 1 to 3-4% of all ischemic strokes. [1] BAO is one of the scenarios of posterior circulation ischemia (PCI), and it is associated with high mortality if left untreated. [2-4] BAO symptoms could be non-focal and unspecific, such as headache, dizziness, and vertigo, resulting in a delay in the neurological evaluation. [5-7] Timely made diagnosis and treatment are some of the most difficult tasks. Intravenous thrombolysis (IVT) is still considered standard of treatment when performed within 3 to 4.5 hours after the onset of symptoms. [8] Although novel studies show better results when intra-arterial thrombolysis (IAT) or mechanical thrombectomy (MT) is performed. Early studies of endovascular treatment showed that it is associated with high rates of recanalization success, a better outcome for the patient, and a reduction in mortality rates. [1, 9]
One of the most important arteries of the human body is the basilar artery (BA). [10] It is formed by the convergence of the left and right vertebral arteries at the junction of the pons and medulla. It runs along the basilar sulcus of pons and branches out into numerous ramifications which include the following: anterior inferior cerebellar artery, pontine arteries, labyrinthine artery, superior cerebellar artery, and posterior cerebral arteries. The vertebrоbasilar arterial system supplies the posterior portion of the circle of Willis and receives about 20 % of cerebral blood flow. Its main responsibility is to supply the brainstem, thalami, cerebellum, and parts of the occipital and temporal lobes. [11, 12]
Etiology
The most frequent causes of BAO are local thrombosis and artery-to-artery thromboembolism originating from arteriosclerotic lesions. [4]
Atherosclerosis is one of the main reasons for BAO. BA is the intracranial artery most commonly affected by the atherosclerotic process. [12] Usually, it affects the mid-portion of the basilar artery, followed by the vertebrоbasilar junction. Atherosclerotic BA stenosis is the most common cause of BAO in older patients. [15] Occlusion due to atherosclerosis is usually seen in the sixth and seventh decade of life.
Other etiological factors that lead to ВАО are artery-to-artery embolization (most frequent cardiac origin emboli) and vertebral artery dissections, affecting respectively 30-35% and 6-8% of patients. [4] The typical locations of the obstruction with arterioembolic mechanism [4] are the vertebrobasilar junction and the distal third of the BA, especially at the top of this artery. [13] It is most prevalent in the fourth decade of life. [8, 10, 14-16]
Dissections are more often seen in the extracranial vertebral artery and are most commonly associated with neck injuries, yoga practice, and cervical chiropractic adjustment. Although rare, dissection can also be seen in the intracranial segment, most often spontaneous in these cases. Vertebrobasilar dolichoectasia, an anatomic variant consisting of enlargement and extreme dilatation of the vertebral/basilar artery, has been shown also to predispose to BAO through a reduction in flow velocity leading to local thrombus formation. [5, 17] Other rare causes include meningitis, coagulopathy, arteritis, cervical trauma, aneurysms, hereditary arteriopathies, as well as complications after endovascular procedures and neurosurgery. [4] One recently described case of reversible stenosis of the BA is due to hemoconcentration, a condition that is frequently found in psychiatric patients with severe depression. [7]
Pathogenesis of the disturbances of the Posterior Circulation (PC) disease differs from Anterior Circulation (AC) disease in their pathophysiology, clinical presentation, symptoms development, optimal imaging methods, and the available treatments. It is common to divide diseases of PC into two categories. On one hand, acute BAO has a more rapid onset, the diagnosis must be made quickly and the following treatment should not be delayed because of the extremely poor natural course. On the other hand, BAO is characterized by more slowly developing ischemia in the PC leading to non-specific symptoms and early warnings of PC disease that now can be related to ischemic events in all PC vessels. These signs and symptoms occur much earlier than those in the AC [13]. In both scenarios, the treatment of choice has to be the removal of the BA thrombosis or embolus because if left untreated, the clinical evolution is usually extremely unfavorable.
Epidemiology and risk factors
Available data on the frequency, incidence, and prevalence of the BAO is still insufficient. A posterior circulation obstruction is a common form of stroke affecting in total about 1/5 of all patients with stroke [13]. BA thrombosis accounts for about 27% of the ischemic strokes occurring in the posterior circulation. Men are affected twice as much as women. (10) Acute BAO is a rare stroke syndrome comprising only about 3% of all ischemic strokes. [17, 18]
All the risk factors typical for the development of atherosclerosis can be associated with vertebrobasilar ischemia. [19-21] These include arterial hypertension, diabetes mellitus, dyslipidemia, smoking, age, gender, family history, and genetic factors. Furthermore, patients with a history of coronary artery disease or peripheral artery disease are at increased risk. [22] Other etiological causes may include cardioembolic conditions such as atrial fibrillation, infective endocarditis, vertebral artery dissection, and systemic hypercoagulable states [23].
Clinical presentation and diagnosis
BAO requires quick diagnosis and immediate treatment. [12] Dizziness and vertigo are the most common findings in the history of the patient, suggesting vertebrobasilar ischemia. Vertigo, which is the most common symptom, is defined as a sensation of spinning and usually indicates dysfunction of the peripheral vestibular or central vestibulocerebellar system. Dizziness is associated with lightheadedness or lack of mental clarity. Vertigo and dizziness caused by BAO are often connected with other brainstem or cerebellar symptoms. When vertigo is the only symptom it is very important to establish whether its origin is central or peripheral. In this case, the head-impulse, nystagmus, test of skew (HINTS) examination is a useful bedside test to distinguish peripheral from a central lesion. In patients with PCI, headache is a common presenting symptom. [3, 7, 17, 24-27]
Other symptoms include syncope, "drop attacks” (patient feels sudden weakness in the knees and fall on the ground), diplopia or loss of vision, paresthesia, confusion, dysphagia, and dysarthria. [4] If vertebrobasilar ischemia (VBI) advances into a brainstem infarction, several syndromes may arise depending on the location: lateral medullary syndrome, medial medullary syndrome, basilar artery syndrome, and labyrinthine artery syndrome. Other aspects of the history that should be noted during the clinical evaluation are reproducible symptoms during positional head changes. For example, a syncope is possible while turning the head laterally (Bow Hunter’s syndrome) or during head extension. [28-30]
In patients with PCI, headache is not an unusual symptom and it seems to be caused by irritation of the trigeminovascular afferents located in the brainstem. Headache has predominantly occipital localization and may occur two weeks before the stroke. [24]
Depending on the onset of symptoms, three major clinical types of BAO presentation have been described:
a) Sudden onset (without preceding events) of severe motor and bulbar symptoms (ophthalmoplegia, quadriplegia, and anarthria) combined with reduced consciousness [7];
b) Abrupt but with prodromal symptoms such as transient double vision, dysarthria, vertigo, paresthesia, which precede the monophasic BAO symptoms by several days or even weeks or months [21];
c) Progressive clinical presentation characterized by a gradual course of posterior circulation symptoms such as blurred vision, balance disturbance, bilateral paresthesia, or motor weakness, which finally are associated with reduced consciousness. [4, 31]
Some differentials with overlapping symptoms should be considered. These include meningitis, basilar migraine, cerebellar hemorrhage with brainstem compression, cerebellar infarct or hemorrhage with edema, space-occupying lesions in the posterior fossa including metastatic disease, and supratentorial mass lesions with mass effect, herniation, and brainstem compression. [32, 33]
Evaluation
The primary goal of the examination is to establish the localization of vascular lesions and specify if acute intervention is indicated to achieve recanalization in a time-dependent manner. Laboratory studies are of little value but may include a complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT). Young patients with a low possibility of atherosclerosis should be investigated for hereditary procoagulant conditions. These include protein C, protein S, antithrombin III deficiencies, lupus anticoagulant, and anticardiolipin antibodies, and homocysteine levels. Thorough searching for arrhythmogenic etiology on ECG should be done [10].
Imaging methods for diagnosis
Computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used as a screening imaging technique to evaluate posterior circulation disease. Nowadays, 7T MRI angiography (MRA) represents a new valuable imaging method for the evaluation of PCD. [13] All of Doppler sonography, CT, contrast-enhanced CT angiography (CTA), MRI, MRA can be used in the acute setting to evaluate patients with suspected BAO. [4]
CT is usually the first imaging study performed. Hemorrhagic pathology or a large area of ischemic insult can be diagnosed, but it is less effective as a screening tool for evaluation of brainstem, cerebellum, and posterior circulation. Filling defects within the BA could be seen with CTA. However, CT scanning is less sensitive for the detection of early ischemia or vascular occlusion compared to MRI/MRA.
The gold standard for definitive diagnosis of BAO is still conventional cerebral angiography. It is superior to MRI and CT angiography and is more and more used in the context of catheter-based endovascular IA treatments (mechanical thrombectomy/ thrombaspiration procedures).
Treatment
Treatment of BAO aims to recanalize the occluded artery and salvage the brain tissue. BA recanalization can reduce mortality and increase the patient’s chances of functional recovery through reperfusion therapy. The reperfusion therapy includes IVT, IAT, and mechanical endovascular thrombectomy/thrombaspiration. [34] After the diagnosis of BAO is made, IVT or endovascular treatment can be performed to recanalize the occluded artery depending on the treatment time-window. Despite the lack of large scientific evidence, in the majority of patients with BAO, IAT or IVT has to be performed because if left without any reperfusion treatment the natural prognosis of BAO is extremely poor. The earlier the intervention is performed, the better are the results. [35-39]
The IVT is contraindicated in patients with acute ischemic stroke with the onset of symptoms of more than 4.5 h, in patients with head trauma in the last 3 months before the acute ischemic stroke, in patients with intracranial or subarachnoid hemorrhage, blood pressure ≥185/110 mmHg, or low serum glucose levels ≤2,8 mmol/l. Small case series and trials have shown IAT is a highly prospective intervention in patients with contraindications for IVT because of its higher recanalization rate and lower bleeding risk. [34]
In the management of acute ischemic stroke, IVT still is considered standard strategy. Three large multicenter studies – SITS-MOST, the IST-3 and ECAS III evaluated the safety and efficacy of IVT, with a therapeutic window of 3, 4.5, and 6 hours, respectively. A point should be made that most of the patients in these studies had anterior circulation ischemia because the localization of stroke in posterior circulation is often quoted as an exclusion criterion. [40, 41] According to nowadays American Stroke Association guidelines for the early management of patients with acute ischemic stroke - IV alteplase is recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptoms onset or patient last known well. [42]
Some uncontrolled studies, in which IAT was used, showed a high recanalization rate, around 65%. (31) The efficacy of fibrinolytic treatment with IVT or IAT in posterior circulation strokes was evaluated in only one prospective, observational study of patients with BAO-BASICS (The basilar artery interventional cooperation study). [43] In this study, the modified Ranking score (mRS) was used as an endpoint of the comparison in the efficacy between these treatments. In patients with mRS 0-2, with mild to moderate BA stroke, IVT treatment showed better outcomes compared to intra-arterial treatment, 53% to 30%, respectively. When considering patients with severe stroke, with a high mRS score (at least 2 or more), the outcome did not differ significantly. Recanalization occurred in 72 % of patients treated with endovascular procedures compared to 63% of patients treated with IVT and that was associated with increased functional independence. [44]
In a multicenter, randomized study evaluating 131 Chinese patients, both per-protocol and as-treated analysis showed that thrombectomy was superior to the best medical treatment in BAO. [45] In a recently published single-center observational study, a Swedish group reported 73% of successful recanalization with combined catheter-based intra-arterial interventional techniques in patients presenting with BAO. [46]
Our group published a case of successful combined catheter-based treatment (mechanical recanalization, balloon angioplasty with a non-compliant balloon, and low dose intra-arterial fibrinolysis) in a 67-year-old patient with BAO causing tetraplegia and coma. [47] We showed the result of a particular case of successful consecutive contact thrombaspiration of BAO and the two posterior cerebral arteries performed with Penumbra 5 MAX (Penumbra, Inc., USA) thrombaspiration catheter in a patient admitted 2 hours after a sudden onset of dizziness, deep somnolence, and fluctuating blurred speech.
According to the European Stroke Organization, there is consensus among the panel (11/11 votes) that in analogy to anterior circulation large vessel occlusion (LVO) and with regard to the grim natural course of BAO, the therapeutic approach with IVT plus MT should strongly be considered [48].
According to 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: (AHA/ASA): Although the benefits are uncertain, the use of MT with stent retrievers may be reasonable for carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, BA, or posterior cerebral arteries - IIb. The use of MT devices other than stent retrievers as first-line devices for MT may be reasonable in some circumstances, but stent retrievers remain the first choice – Iib [42].
Endovascular treatment both with stent retriever and contact aspiration thrombectomy as a first-line approach was safe and effective methods in a multicenter retrospective observational study which included 212 consecutive patients with acute BAO treated with one or the other technique. [49] In the published small trials MT was associated with low rates of mortality (13%), procedure-related complications (4.2%), or symptomatic hemorrhage (1.9%). The application of MT in BAO was associated with high rates of favorable outcomes (44.8%) and high rates of successful reperfusion (91.5%). [49-51]
The treatment window for acute BA thrombosis is not well defined yet. The commonly accepted time window is at least 12 hours potentially up to 24 hours. A well-accepted common opinion is that the treatment window of MT for BAO window has to be much longer than the accepted recommendation for treatment of large vessel occlusion in the anterior circulation stroke - 6 to 8 hours [35-38, 52] probably because of the extremely poor prognosis for patients left without recanalization attempt.
To demonstrate the efficiency of the endovascular treatment of stroke we present a case of a 62-year-old male who was referred to the clinic due to one-week symptoms of left hemiplegia, dysarthria, vertigo, ataxia, and balance problems. Duplex and Doppler ultrasound examination of the neck arteries showed absence of flow in the right vertebral artery, significantly reduced post-stenotic pattern of blood flow in the left V2 segment of the vertebral artery, 70% stenosis of the left internal carotid artery (LICA) and normal flow in the right internal carotid artery (RICA). Angiography confirmed the ultrasound findings (Figure 1): occlusion of the right vertebral artery, subtotal occlusion of the proximal left vertebral artery, 70% stenosis of LICA and patent RICA. Using Fielder XT (Asahi Intecc, Japan) wire for chronic total occlusions, the proximal left vertebral stenosis was passed through. (Figure 2) After pre-dilatation, Resolute Onyx 4.5/22 mm stent (Medtronic. USA) was implanted in the proximal left vertebral artery, V0/1 segment. A second subtotal occlusion at the distal left vertebral artery was revealed in the V4 segment. (Figure 3) It was treated by pre-dilatation followed by implantation of the Resolute Onyx 2.75/22 mm stent (Medtronic, USA). Final angiography showed excellent results and restored TICI-3 flow in the vertebrobasilar system. (Figure 4) Two months were needed for the patient to improve his ataxia and dysarthria, and to recover from hemiplegia. The follow-up CTA showed preserved flow and patent vessels. (Figure 5) The patient had gone back to his normal life.
Methods
Our in-hospital protocol is to evaluate all patients with BAO for endovascular treatment. All the patients with onset of stroke for less than 6h are treated by thrombaspiration and/or IAT. Our primary endovascular treatment method is ADAPT - A Direct Aspiration First Pass Technique. Patients with the onset of stroke for more than 6h but less than 24h are carefully evaluated and treated by the same means as the <6h group if they do not match one of these criteria: bilateral mydriasis, absent brainstem reflexes, hemorrhage on brain imaging, profound coma, limited life-expectancy despite stroke treatment. Patients with BAO older than 24h are evaluated individually and treated by endovascular means only if they fall into the group with progressive symptom presentation or they have enough retrograde circulation from the posterior communicating arteries, visualized on CTA, ensuring the viability of the infarction zone.
Conclusion
The BAO is related to high mortality rates and a severe reduction in the quality of life. With the advancement of pharmacological treatment and endovascular therapy, reduction in mortality and disability rates in these patients can be achieved. There is a gap in the evidence about the best method for the treatment of BAO. New methods have a proven role in the treatment of anterior brain circulation disease, but small patient case series and some systematic protocols showed that endovascular treatments were also safe and effective for BAO, when performed by experienced operators. Modern methods of treatment applied on time are related to a significant reduction of mortality and better prognosis in this otherwise unfavorable group of patients.
Funding
The authors received no funding for this work.
Disclosures
The authors have no disclosures.
Acknowledgements
None
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
