There are few reports describing stroke due to the acute occlusion of the vertebral artery (VA) origin successfully treated by endovascularily. The authors report a case of 78-year-old man suffering from stroke owing to acute VA origin occlusion associated with contralateral hypoplastic VA leading to basilar artery (BA) thrombosis. Cerebral angiography demonstrated that the right VA was occluded at its origin, the left VA was hypoplastic, and BA was filled with thrombus. The occlusion of VA origin was initially passed through with a microcatheter and microwire. Hereafter, angioplasty was performed followed by stenting with a coronary stent. The VA origin was successfully recanalized. Next, a microcatheter was navigated intracranially through the stent and fibrinolysis was performed for BA thrombus. The patient's symptoms gradually improved postoperatively. Stroke due to acute VA origin occlusion leading to BA thrombosis was successfully treated by angioplasty and stenting followed by intracranial fibrinolysis.
Atherosclerotic occlusive disease of the extracranial vertebral artery (VA) is a major cause of stroke and transient ischemic attack (TIA) of the posterior circulation. Atherosclerosis commonly affects the origin and proximal portion of the VA [
The authors report a case of stroke owing to an acute occlusion of VA origin associated with contralateral hypoplastic VA leading to basilar artery (BA) thrombosis, which was treated by angioplasty with stenting and intracranial fibrinolysis.
A 78-year-old man had a history of hypertension and coronary artery bypass graft for angina pectoris. However, he was not on any antiplatelet/anticoagulant medication. He was discovered after having fallen down on the street and was transferred to the hospital. He presented consciousness disturbance, left hemiparesis, dysarthria, and gaze palsy. The National Institutes of Health Stroke Scale (NIHSS) on admission was 18. MR diffusion weighted image (DWI) demonstrated a high-intensity area in the right cerebellum and brain stem (
Diagnostic cerebral angiography demonstrated that the right VA was occluded at its origin (
The patient presented the discrepancy between the lesion on DWI and severe clinical symptom (DWI-clinical mismatch). A recombinant tissue plasminogen activator was not administered because the onset of symptoms was unknown and MR T2/FLAIR images suggested the possibility of progress of the time from onset. Therefore, endovascular intervention was immediately performed (130 minutes after the arrival at hospital).
Intervention was carried out transfemorally under systemic heparinization. A 6 Fr guiding catheter (Envoy, Cordis Neurovascular, Miami, FL, USA) was advanced to the right subclavian artery. Penetration of the occlusive site proved too difficult for the guidewire or protection devices alone Therefore, the occlusion of VA origin was initially crossed with a microcatheter (Excelsior SL-10, Stryker Neurovascular, Fremont, CA, USA) and microwire (Asahi Chikai14, Asahi Intecc, Nagoya, Aichi, Japan) (
Dual antiplatelet therapy with 100 mg aspirin and 75 mg clopidogrel daily was administered, and anticoagulant therapy with intravenous argatroban was continued for 1 week. The patient's symptoms did not deteriorate after intervention, and all his symptoms were gradually improved postoperatively during the hospitalization. Finally, he left the hospital for rehabilitation 4 weeks later because dysarthria and left hemiparesis still remained. NIHSS at discharge was 5. And modified Rankin Scale score at 3 months was 3.
A follow-up MR image was obtained 1 week later. MR DWI disclosed a high-intensity area around the right SCA territory and the left cerebellar hemisphere mainly fed by the distal part of the left AICA. MR DWI high-intensity area around brain stem was not enlarged postoperatively in comparison with preoperative MR image. MRA demonstrated no re-occlusion of the VA origin and showed clear visualization of the right VA, BA and left SCA despite poor visualization of the distal right SCA (
Atherosclerotic occlusive disease of VA most commonly affects the origin and proximal portion of the VA [
This article demonstrated a case of stroke due to an acute VA origin occlusion associated with hypoplastic contralateral VA, which led to BA thrombosis, successfully treated by PTA with stenting and intracranial fibrinolysis. As you may know, there were a number of reports about acute occlusion at the cervical portion of the internal carotid artery (ICA) due to atherosclerosis steno-occlusive disease. Cervical ICA occlusion often has concomitant intracranial occlusion [
The current literature has demonstrated the safety and efficacy of PTA with stenting for VA origin stenosis. However, the cases almost all involved the non-acute period [
The concerns with the endovascular approach for this setting include two cautions. First, the difficulty in penetrating and navigating the devices across the occlusive site. It carries the risk of iatrogenic dissection or perforation of VA caused by a stray wire-tip. In the present case, a microcatheter and a microguidewire were used to raise the support and tractability for crossing the occlusion site. Second, the risk of distal migration of clots or debris into the intracranial arteries. In the present case, distal embolism did not occur, even though an embolic protection device was not used because of time limitation. However, the previous literature revealed that an embolic protection device might be useful for preventing intracranial embolisms during procedures. Iwata et al. [
For the treatment of intracranial lesion, fibrinolysis is convenient regarding the distal accessibility. Mechanical thrombectomy is one of the treatment choices if the access of devices is feasible.
MR DWI acquired on the day of symptom showed high-intensity in the right cerebellum, faint high-intensity in the right brain stem, and several small high spots (