Endovascular Stenting of Vertebral Artery Dissection in Acute Ischemic Stroke

Mehrnoush Gorjian,Matthew Koch,Scott B Raymond,Aman B Patel

doi:10.11648/j.cnn.20190304.11

Mehrnoush Gorjian, Matthew Koch + Show 2 more

Open Access

https://doi.org/10.11648/j.cnn.20190304.11

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Abstract

Background: Vertebral artery (VA) dissection causing acute stroke is commonly treated with anticoagulation and rarely requires stenting. While stenting for atherosclerotic stenosis of VA is an established and efficient treatment option, the safety of stenting for VA dissection has not been studied. Case information: We report the technical challenges associated with stenting of a proximal VA dissection in a 74 year-old male with NIHSSS > 20 outside of the time window for thrombolytic therapy presenting with acute basilar artery thrombus and a hypoplastic contralateral VA. Methods: A coronary Drug-Eluting Stent (DES) was implemented in right VA following balloon angioplasty and basilar artery thrombolysis to maintain the patency of the dissected area in proximal VA. Results: The procedure was completed without complication. Postoperative Digital Subtraction Angiography (DSA) confirmed the patency of the vertebrobasilar system. There was no evidence of significant residual stenosis in the right vertebral artery on the follow up Computed Tomography Angiography (CTA) 2 months after the stent placement. Conclusion: Endovascular stenting of proximal VA dissection in the setting of acute ischemic stroke is relatively safe and feasible. It could be particularly considered in patients ineligible for IV thrombolysis with a hypoplastic contralateral VA. Further studies are needed to evaluate the long-term safety and efficacy of stenting for VA dissection.

Highlights

Endovascular therapy has emerged as a primary treatment for patients with large vessel occlusion in the anterior circulation
Occlusion in posterior circulation is the cause of approximately 12% of acute strokes and is associated with higher mortality rates compared to acute anterior circulation strokes
Post-operative Computed Tomography Angiography (CTA) showed the resolution of filling defects in the basilar artery without significant residual stenosis in the right vertebral artery

Summary

Introduction

Endovascular therapy has emerged as a primary treatment for patients with large vessel occlusion in the anterior circulation. Occlusion in posterior circulation is the cause of approximately 12% of acute strokes and is associated with higher mortality rates compared to acute anterior circulation strokes. The patients with posterior circulation stroke are less likely to undergo endovascular treatment. [2,3,4] While stenting for atherosclerotic stenosis of VA is an established and efficient treatment option [5,6,7] and the rate of in-stent stenosis is lower with Drug-Eluting Stents (DESs) compared to Bare Metal Stents (BMSs) [8], the safety of stenting for VA dissection has not been previously presented. The patients with posterior circulation stroke are less likely to undergo endovascular treatment. [1] Vertebral Artery (VA) dissection is an uncommon but increasingly recognized etiology of stroke. [2,3,4] While stenting for atherosclerotic stenosis of VA is an established and efficient treatment option [5,6,7] and the rate of in-stent stenosis is lower with Drug-Eluting Stents (DESs) compared to Bare Metal Stents (BMSs) [8], the safety of stenting for VA dissection has not been previously presented. [9]

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