Acute Vertebral Artery Origin Occlusion Leading to Basilar Artery Thrombosis Successfully 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 (). MR T2 weighted and fluid-attenuated inversion recovery (FLAIR) images showed subtle ischemic change. MR angiography (MRA) showed faint visualization in the distal part of BA and bilateral superior cerebellar arteries (SCA) ().\nDiagnostic cerebral angiography demonstrated that the right VA was occluded at its origin (), and that the left VA was hypoplastic (). The distal right VA after the midcervical portion was supplied with collateral flows via external carotid arteries and cervical arteries (). The BA was filled with thrombus, although it was supplied by the antegrade flow from ipsilateral VA and the retrograde collateral flow from posterior communicating arteries. The right SCA was occluded at the origin. The left VA ended at the extracranial portion, while the left anterior inferior cerebellar artery (AICA) widely covered the left cerebellum.\nThe 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).\nIntervention 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) (). Hereafter, the microcatheter was replaced by a balloon catheter (Gateway 2.0 mm diameter and 15 mm length, Stryker Neurovascular), with catheter exchange using a long guidewire (Transcend EX floppy 300 cm length, Stryker Neurovascular). Percutaneous transluminal angioplasty (PTA) was performed followed by stenting with a coronary bare metal stent (Integrity; 3.5 mm diameter and 18 mm length, Medtronic, Minneapolis, MN, USA). Finally, VA origin was successfully recanalized (). Blood was manually aspirated from the guiding catheter during and after balloon inflation to avoid distal embolism. No distal emboli were detected post-stenting. Next, a microcatheter was navigated intracranially through the stent and fibrinolysis with urokinase (total 24,000 IU) was performed for BA thrombus. Mechanical thrombectomy was not selected because of the inaccessibility. The guiding catheter was not stable in the subclavian artery and it seemed to be difficult to navigate the guiding catheter for thrombectomy through the stent placed at VA origin. Fibrinolysis was moderately effective although BA thrombus still partially remained (). The operation was finished reluctantly because 3 hours had passed after starting intervention and approximately 5 hours after arrival at the hospital.\nDual 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.\nA 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 ().