Occlusion Of Left Vertebral Artery Research Articles

Bow–Hunter Syndrome Due to Tandem Lesions; A Case Report

AbstractBow–Hunter syndrome (BHS) includes a form of stroke caused by dynamic factors affecting the extracranial vertebral artery (VA), such as rotation-induced flow disturbance at the atlantoaxial level. BHS is a rare condition that can result from a variety of factors, including abnormal bone compression and vertebral instability. So far, there have been no reports in which both vertebral instability and osteophytes compress the VA at different sites, leading to stroke. Herein, we present a rare case of stroke attributed to BHS involving thrombosis formation due to osteophyte compression at C3/4 and VA occlusion due to vertebral instability at the C4/5 overlapped. A 72-year-old male presented with rotational vertigo and vomiting associated with a cerebellar infarction. Digital subtraction angiography revealed severe stenosis of the left VA with an intra-arterial thrombus. Percutaneous transluminal angioplasty improved the stenosis; however, intravascular ultrasound revealed compression of the VA by osteophytes at C3/4. Additionally, left VA occlusion at C4/5 was confirmed because of vertebral instability. The osteophyte was removed via the anterolateral approach, and the VA was decompressed. The patient's postoperative course was uneventful, with no recurrence for more than 2 years. BHS can occur in the lower cervical spine when vertebral instability coincides with intimal arterial damage caused by osteophytes at other sites.

Hyperacute thrombosis of a vertebral artery stent with a single missed dose of a P2Y12 inhibitor and poor stent wall apposition: illustrative case.

Iatrogenic vertebral artery injury during surgery can cause pseudoaneurysm, hemorrhage, thrombosis, ischemia, or death. Strategies to prevent cerebrovascular embolic complications include surgical ligation, endovascular stenting, and/or antiplatelet therapy. A 73-year-old female with a known right vertebral artery occlusion underwent a C2-3 laminectomy, complicated by left vertebral artery injury and occlusion with subsequent posterior circulation ischemia. She underwent immediate angioplasty and stenting of the injured artery with undersized drug-eluting stents. Dual antiplatelet therapy of aspirin 81 mg daily and ticagrelor 90 mg twice daily was initiated. On two occasions, more than 6 months after stenting, holding a single ticagrelor dose led to in-stent thrombosis and embolic stroke within hours of the missed dose. Lifelong therapy with ticagrelor was favored over further procedural intervention. It is recommended to prioritize optimal wall stent apposition with oversized stents in patients without collateral circulation. The risk of thromboembolism due to poorly apposed stents is very high, even in delayed (> 6 months) settings. Stent construct revision or bypass grafting may not be feasible or desirable options. For patients without wall apposition, endothelialization may not occur, necessitating lifelong P2Y12 inhibitor therapy to prevent recurrent thromboembolic events. https://thejns.org/doi/10.3171/CASE24296.

Acute left vertebral artery dissection and right vertebral artery occlusion in a middle-aged man: A case report

Spontaneous left Vertebral Artery Dissection (VAD) is an uncommon but very important etiology of acute posterior circulation stroke. We reported a case of a 43 years old man, who came with the complaint of chest pain with sudden onset, severe sweating

Using a low-metal-density stent for thrombectomy-resistant vertebrobasilar occlusion due to thrombus migration from a thrombosed vertebral artery aneurysm: illustrative case.

Thrombosed intracranial aneurysms can lead to large vessel occlusion as a result of spontaneous thrombosis. Although mechanical thrombectomy is likely effective, recurrent thromboembolism can occur if the thrombotic source remains untreated. The authors describe a case of recurrent vertebrobasilar artery occlusion due to thrombus migration from a large thrombosed vertebral artery (VA) aneurysm that was successfully treated with mechanical thrombectomy followed by stenting. A 61-year-old male previously diagnosed with a large, thrombosed VA aneurysm presented with right hypoesthesia. Imaging on admission showed left VA occlusion and an acute ischemic lesion in the left medial medulla. His symptoms worsened, with complete right hemiparesis and tongue deviation occurring 3 hours after admission, and mechanical thrombectomy was performed to recanalize the left-dominant VA. Despite several attempts, reocclusion of the vertebrobasilar system occurred after each mechanical thrombectomy because of repeated thrombus formation in the thrombosed aneurysm. Therefore, a low-metal-density stent was deployed to prevent thrombus migration into the parent artery, which resulted in complete recanalization and rapid improvement of the symptoms. Stenting with a low-metal-density stent for recurrent embolism secondary to thrombus migration from a large thrombosed aneurysm was feasible in the acute stroke setting.

Asystole, A Rare Cardiac Complication of Lateral Medullary Infarction: Case report and Literature Review. (P2-5.010)

<h3>Objective:</h3> We report a case of lateral medullary infarction leading to asystole, and we discuss the diagnosis, management, and prognosis of patients with this rare complication. <h3>Background:</h3> Clinical presentations of lateral medullary stroke vary. Wallenberg syndrome is the most common presentation, which includes vertigo with nystagmus, ataxia, ipsilateral sensory deficits in the face, bulbar muscle weakness, and ipsilateral Horner’s syndrome. The nucleus tractus solitarius, the dorsal vagal nucleus, and the nucleus ambiguous in the lateral medulla oblongata play a critical role in autonomic regulation and have centers for respiratory, cardiac, and vasomotor reflexes. Despite this, cardiac arrhythmias such as asystole are a rare clinical manifestation of lateral medullary stroke. <h3>Design/Methods:</h3> Case report and literature review. <h3>Results:</h3> A 64-year-old man with hypertension, previously involved in a motor vehicle accident, presented with acute onset dysphagia, left facial droop, and left eye ptosis. CT of the head did not show any acute stroke or hemorrhage. CT angiography of the head and neck showed left vertebral artery (V3/V4 segment) occlusion. He received IV thrombolysis. Post thrombolysis, he had bradycardia evolving to asystole and brief cardiac arrest. MRI of the brain revealed acute left posterior lateral medullary stroke and MR angiography showed left vertebral artery dissection. Cardiac work-up was unrevealing, and he eventually required placement of a dual-chamber pacemaker. Given the absence of respiratory factors and structural heart disease, the bradycardia and asystole were attributed to the lateral medullary stroke. <h3>Conclusions:</h3> Despite the recognized role of the lateral medulla in autonomic regulation, cardiac arrhythmias are rarely associated with lateral medullary infarction. Precise mechanisms are yet to be elucidated, but it remains important to recognize them as a potential complication of this stroke. <b>Disclosure:</b> Dr. Gutierrez Quiceno has nothing to disclose. Dr. Gowda has nothing to disclose. Dr. Kakadia has nothing to disclose.

Teaching Neuro Images : Dynamic vertebral artery insufficiency

A 20-year-old healthy man presented with transient right upper monoparesis and brain MRI (figure, A) demonstrated left thalamic infarct. He presented 2 weeks later with left hemiparesis at basketball practice and right thalamic infarct (figure, B). Stroke risk factor workup was unrevealing. Conventional angiography demonstrated normal left vertebral artery course (figure, C and E), but dynamic left vertebral artery occlusion during 36° rightward head turn (figure, D and F). Bow hunter syndrome, first described in an archer,1 is eponymous for positional occlusion of the vertebral artery. This is associated with strokes from dynamic hypoperfusion. The patient remains symptom-free 1 month after microsurgical clip sacrifice of the left vertebral artery.

Abstract Number ‐ 113: A Lateral Medullary Infarct Complicated by Central Hypoventilation Syndrome

Introduction A 43‐year‐old male with no known past medical history presented to a primary stroke center for sudden onset headache, nausea, vomiting, and dizziness while driving. A computed tomography angiogram of the head and neck revealed a left vertebral artery occlusion, and the patient was transferred to our comprehensive stroke center for further evaluation and treatment. Upon arrival at our facility, the patient was noted to have a national institute of health stroke scale score of 7 with left facial droop, dysarthria, and right upper extremity dysmetria. A cerebral angiogram revealed a tortuous left vertebral artery with dissection in the V4 segment. Subsequent brain diffusion weighted imaging revealed an acute infarct in the right lateral medulla measuring 1.4cm and several acute cerebellar infarcts. (fig. 1) In the postangiography period, the patient had dysphagia, sialorrhea, multiple aspiration episodes, and oral secretions requiring early tracheostomy and percutaneous endoscopic gastrostomy on hospital day (HD) #6. The subsequent hospital course was complicated by prolonged singultus lasting until HD #23 and repetitive vomiting requiring a transition from a gastric to a gastro‐jejunal feeding tube. Methods A central hypoventilation syndrome (CHS) prolonged ventilator weaning. Despite preserved ability to take large‐volume voluntary breaths, the patient experienced multiple episodes of sleep‐associated apnea and rapid shallow breathing pattern during daily spontaneous breathing trials (SBT). The apnea episodes were registered with ventilator apnea alarms set at 20 seconds. This pattern continued when attempting an SBT utilizing a T‐piece adaptor. The ability to maintain adequate minute ventilation in an asleep state subsequently improved, and the patient was able to tolerate 48 hours of spontaneous breathing with no apnea on HD #35. Results Few cases of CHS secondary to lateral medullary infarction (LMI) have been documented in the literature.(1‐3) As the respiratory drive originates from neurons in the latero‐rostro‐ventral medulla, infarcts in this brainstem region may lead to respiratory failure. More specifically to our patient, ataxic breathing may result from lesions in the rostro‐ventral medulla with yawning and hiccups being seen in lesions to the posterolateral medulla.(4) As our patient presented with a sizable 1.4cm lesion, likely impairing these brainstem centers, it is expected that his symptoms would account for multiple respiratory symptoms. The unique feature of the acquired CHS in the setting of LMI is its unilateral location implying lateralization of the respiratory control. In addition to the aforementioned symptoms, his lesion likely led to prolonged weaning from the ventilator as has been described previously.(5) Conclusions This case raises awareness regarding potentially disastrous complications of the lateral medullary syndrome like central hypoventilation syndrome. We urge caution and careful evaluation of patients with lateral medullary infarctions for disorders of the respiratory control system.

Interventional Distal Embolization before Corrective Cervical Spinal Surgery for Posttraumatic Vertebral Artery Occlusion: A Case Report and Review of the Literature.

A traumatic vertebral artery (VA) injury may result in serious cerebral infarction in the vertebrobasilar area. However, the approach to its diagnosis and the optimal treatment have not yet been established. We present a patient with traumatic occlusion of a unilateral VA due to the multiple cervical spine fractures who required decompression and fixation, in whom the injured VA was coil embolized distal to the occlusion prior to the cervical spine surgery. A 47-year-old woman was injured in a car accident and, presented with C6-C7 superior articular process fractures and C2-C3 ossification of the posterior longitudinal ligament (OPLL) with sensory hypoesthesia and motor palsy of the left upper limb. MRA showed left VA occlusion and patent contralateral VA. DSA showed left VA occlusion from the origin to C5/6 and its antegrade flow by collateral orthodromic circulation from the muscular branches. To prevent vertebrobasilar infarction due to migration of the thrombus from the occluded VA which was recanalized by surgical fixation, distal coil embolization of the injured VA by navigating a microcatheter through the contralateral VA across the vertebrobasilar junction was performed. Neither ischemic events nor new neurologic symptoms occurred during follow-up. Preoperative coil embolization to a traumatic VA occlusion can be one of the therapeutic choices to prevent thromboembolic stroke after cervical spine surgery. When the proximal segment of the VA was injured and VA occluded from origin, this treatment strategy is feasible, safe, and effective.

Carotid-Cavernous Fistula Presenting With Bilateral Abducens Palsy.

Carotid-Cavernous Fistula Presenting With Bilateral Abducens Palsy.

P.101 Lateral medullary syndrome due to left vertebral artery occlusion in a boy post flexion neck injury

Background: Wallenberg’s syndrome (WS), or lateral medullary syndrome is rare in pediatrics, but is not uncommon in adults. It is characterized by neurological deficits due to an ischemic lesion in the lateral medulla. Methods: Case report Results: We describe a 17-year-old boy who developed WS in the context of hyperflexion injury to the neck while diving in shallow water with vertebral dissection as a presumed etiology. He had ‘crossed’ neurological deficits above and below the neck. His MRA showed intra and extracranial left vertebral artery occlusion and his MRI showed T2W/FLAIR signal abnormality involving the left lateral medulla and inferomedial aspect of the cerebellum in keeping with infarcts secondary to the left vertebral artery thrombosis and occlusion of the left posterior inferior cerebellar artery. He was started on anti-coagulation after spinal surgery. On discharge, he had persistent dysphagia which prompt a gastrostomy tube placement prior to transfer to a rehabilitation center. Conclusions: Our case demonstrates that WS can occur post flexion injury in the pediatric population. The presence of crossed neurological findings above and below the neck in the context of neck injury is an important diagnostic clue that should prompt imaging study focusing on the brain stem and the posterior fossa vascular structures.

Lateral Medullary Syndrome due to Left Vertebral Artery Occlusion in a Boy Post Flexion Neck Injury (P6.217)

Lateral Medullary Syndrome due to Left Vertebral Artery Occlusion in a Boy Post Flexion Neck Injury (P6.217)

Stent-assisted coiling of a ruptured vertebrobasilar junction aneurysm via direct vertebral artery puncture

A 78-year-old patient was admitted with subarachnoid hemorrhage caused by rupture of a broad-based vertebrobasilar junction aneurysm. Direct endovascular access to the vertebrobasilar circulation was not possible due to chronic...

Fatal Vertebral Artery Injury in Penetrating Cervical Spine Trauma.

Study Design. This case illustrates complications to a vertebral artery injury (VAI) resulting from penetrating cervical spine trauma. Objectives. To discuss the management of both VAI and cervical spine trauma after penetrating gunshot wound to the neck. Summary of Background Data. Vertebral artery injury following cervical spine trauma is infrequent, and a unilateral VAI often occurs without neurologic sequela. Nevertheless, devastating complications of stroke and death do occur. Methods. A gunshot wound to the neck resulted in a C6 vertebral body fracture and C5–C7 transverse foramina fractures. Neck CT angiogram identified a left vertebral artery occlusion. A cerebral angiography confirmed occlusion of the left extracranial vertebral artery and patency of the remaining cerebrovascular system. Following anterior cervical corpectomy and stabilization, brainstem infarction occurred and resulted in death. Results. A fatal outcome resulted from vertebral artery thrombus propagation with occlusion of the basilar artery triggering basilar ischemia and subsequent brainstem and cerebellar infarction. Conclusions. Vertebral artery injury secondary to cervical spine trauma can lead to potentially devastating neurologic sequela. Early surgical stabilization, along with anticoagulation therapy, contributes towards managing the combination of injuries. Unfortunately, despite efforts, a poor outcome is sometimes inevitable when cervical spine trauma is coupled with a VAI.

Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture

A patient with a giant symptomatic vertebrobasilar aneurysm was treated by endoscopic third ventriculostomy for obstructive hydrocephalus followed by treatment of the aneurysm by flow diversion using a Pipeline Embolization...

Atypical Anterior Spinal Artery Infarction due to Left Vertebral Artery Occlusion Presenting with Bilateral Hand Weakness.

BackgroundInfarct of the anterior spinal artery is the most common subtype of spinal cord infarct, and is characterized by bilateral motor deficits with spinothalamic sensory deficits. We experienced a case with atypical anterior-spinal-artery infarct that presented with bilateral hand weakness but without sensory deficits.Case ReportA 29-year-old man presented with sudden neck pain and bilateral weakness of the hands. Magnetic resonance imaging (MRI) of the brain did not reveal any lesion. His motor symptoms improved rapidly except for mild weakness in his left wrist and fingers. Magnetic resonance angiography showed proximal occlusion of the left vertebral artery; a spine MRI revealed left cervical cord infarction.ConclusionsBilateral or unilateral hand weakness can be the sole symptom of a cervical cord infarct.

Evaluation of vertebrobasilar artery changes in patients with benign paroxysmal positional vertigo

The aim of this study was to investigate vertebrobasilar artery (VBA) lesions in elderly patients with benign paroxysmal positional vertigo (BPPV) by magnetic resonance angiography. VBA lesions in patients older than 65 years of age with BPPV were prospectively investigated by magnetic resonance angiography. Vascular risk factors, blood vessel changes, and vertigo severity were recorded. Age-matched individuals without BPPV were included in the control group. Of 126 patients screened for this study, 104 were included. Relevant comorbidities included diabetes (12 patients), hypertension (23 patients), and dyslipidemia (20 patients). Findings included left or right vertebral artery (VA) stenosis or occlusion (22 patients, 21.2%), VA tortuosity (25 patients, 24.0%), VA dominance (20 patients, 19.2%), basilar artery (BA) stenosis or occlusion (nine patients, 8.6%), and BA tortuosity (12 patients, 11.5%). These abnormal vessels differed between BPPV patients and the control group (all P<0.05). The severity of Vertigo did not differ between the abnormal VA and abnormal BA groups (P>0.05), but did differ between the normal group and the abnormal VA or BA group (P<0.05). Vertigo severity correlated with VA stenosis or occlusion, VA dominance, and unilateral or bilateral VA tortuosity. VBA tortuosity and VA dominance were common in BPPV patients and may contribute toward BPPV.

Vertebral artery injury and severely displaced odontoid fracture: the case for early reduction

To report a novel treatment method for vertebral artery occlusion. Vertebral artery injuries have a high association with specific cervical fractures including atlanto-axial fractures, displaced fracture patterns, and transverse foramen fractures. Optimal medical management of the occluded vertebral artery has yet to be determined; however, there is an extremely high complication rate with systemic anticoagulation in these patients. Furthermore, unlike appendicular skeleton fracture-dislocations with vascular injury, there is no clear consensus as to the optimal acute management of the displaced odontoid fracture with or without vertebral artery injury. We report on a severely displaced odontoid fracture that was found to have a vertebral artery injury. Medical records and imaging were reviewed. An 82-year-old female presented to our hospital with a type IIb odontoid fracture after sustaining a ground-level fall. Pertinent physical exam findings were ecchymosis on the left side of her forehead and posterior cervical pain without neurologic deficits. An MRA showed an occluded left vertebral artery. The patient was placed in early cervical traction and the fracture was reduced within 12 h of presentation. Following surgical stabilization, an MR angiogram showed complete reperfusion of the vertebral artery without intimal tear. To our knowledge, this is the first report of a displaced odontoid fracture in which cervical traction was used to restore the perfusion of the vertebral artery. Cervical traction may obviate the need for systemic anticoagulation and should be considered in patients who have an identifiable compression of the vertebral artery even if neurologically intact.

Coiling Occlusion of the Vertebral Artery for a Patient with Recurrent Posterior Circulation TIAs

Recurrent posterior circulation infarcts frequently involve multiple vascular territories, suggesting an embolic source. We describe a patient with left vertebral artery occlusion who had recurrent transient ischaemic attacks due to cerebral embolization originating from the occluded vertebral artery in spite of optimal anticoagulant and antithrombotic treatment. This was successfully managed by coiling occlusion of the vertebral artery with no recurrence of symptoms over one year of follow-up. To our knowledge, this is the first report of coiling occlusion in the treatment of recurrent vertebral artery embolization.

Coronary Subclavian Steal from a Left Internal Thoracic Artery Coronary Bypass Graft due to Ipsilateral Subclavian Artery Stenosis and an Arteriovenous Graft in a Hemodialysis Patient with Left Vertebral Artery Occlusion

Coronary subclavian steal syndrome is an unusual cause of myocardial ischemia, secondary to a reversed blood flow in patients with patent internal thoracic artery coronary bypass grafts. The causes of coronary subclavian steal are either ipsilateral subclavian artery stenosis or upper extremity arteriovenous hemodialysis fistula formation or both. This report involves a 68-year-old woman with left vertebral artery occlusion who developed severe coronary steal in the absence of vertebral subclavian steal due to left subclavian artery stenosis and an arteriovenous hemodialysis graft.

Endovascular Angioplasty for Extracranial Vertebral Artery Occlusion Without Visualization of the Stump of the Artery Ostium

An 87-year-old man presented with extracranial vertebral artery (VA) occlusion and progressive vertebrobasilar ischemia despite maximal medical management. Cerebral angiography showed left proximal VA occlusion, termination of the right VA at the ipsilateral posterior inferior cerebellar artery, and hypoplastic bilateral posterior communicating arteries. Although the stump of the left VA ostium was not visualized, the distal patent artery was reconstituted via muscular branches from the left subclavian artery (SCA). Endovascular angioplasty with a stent for left VA occlusion was performed. The non-visualized VA ostium was extrapolated from the computed tomography angiography findings of the distal patent VA and the partial calcification of the SCA. The occluded VA was penetrated by the guide wire and revascularized by balloon angioplasty with the stent using the support of a snare wire inserted via the left brachial artery for stabilization of the guide catheter. This treatment resulted in resolution of the severe neurological findings.