Vertebral artery stump syndrome

[A case of suspected vertebral artery stump syndrome assessed by CT angiography]

A 55-year-old man developed ischemic stroke in the bilateral cerebellar hemispheres and bilateral occipital lobes. He was admitted to our hospital 17 months later with recurrent ischemic stroke in the posterior circulation. The left vertebral artery (VA) was occluded on brain magnetic resonance angiography but was visualized with a delay on continuous three-phase CT angiography (CTA). Conventional angiography confirmed a to-and-fro blood flow pattern at the distal end of the left VA, therefore the patient was diagnosed with VA stump syndrome (VASS). VASS is a recurrent posterior circulation ischemic stroke caused by thrombi in an occluded unilateral VA. VASS should be suspected in patients with unilateral VA occlusion and repeated posterior-circulation ischemic stroke. The diagnostic criteria for VASS include confirmation of VA occlusion and the presence of an antegrade flow component at the distal end. In this case, the presence of collateral circulation in the VA was suspected based on CTA findings, leading to the diagnosis of VASS. It was thus suggested that devising the imaging method of CTA may help diagnose VASS.

Endovascular thrombectomy with versus without intravenous thrombolysis in patients with acute basilar artery occlusion: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

The benefit and safety of intravenous thrombolysis before endovascular thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion (BAO) remains unclear. This article aims to investigate the clinical outcomes and safety of endovascular thrombectomy with versus without intravenous thrombolysis in acute BAO stroke patients.

METHODS

We conducted a comprehensive search of PubMed, Embase, Cochrane, and Web of Science databases to identify relevant literature pertaining to patients with acute BAO who underwent endovascular thrombectomy alone or intravenous thrombolysis bridging with endovascular thrombectomy (bridging therapy), until January 10, 2024. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin Scale at 90 days. The safety outcome was mortality at 90 days and symptomatic intracranial hemorrhage within 48 h. Effect sizes were computed as risk ratio (RR) with random-effect models. This study was registered in PROSPERO (CRD42023462293).

RESULTS

A total of 528 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded. Finally, 2 RCTs and 10 cohort studies met the inclusion criteria. The findings revealed that the endovascular thrombectomy alone group had a lower rate of functional independence compared to the bridging therapy group (29% vs 38%; RR 0.78, 95% CI 0.68-0.88, p < 0.001), lower independent ambulation (39% vs 45%; RR 0.89, 95% CI 0.82-0.98, p = 0.01), and higher mortality (36% vs 28%, RR 1.22, 95% CI 1.08-1.37, p = 0.001). However, no differences were detected in symptomatic intracranial hemorrhage between the two groups (6% vs 4%; RR 1.12, 95% CI 0.74-1.71, p = 0.58).

CONCLUSION

Intravenous thrombolysis plus endovascular thrombectomy seemed to led to better functional independence, independent ambulation, and lower risk of mortality without increasing the incidence of intracranial hemorrhage compared to endovascular thrombectomy alone. However, given the non-randomized nature of this study, further studies are needed to confirm these findings.

Endovascular Treatment May Be Effective in Preventing Recurrence of Ischemic Stroke in Vertebral Artery Stump Syndrome: A Case Series

Vertebral artery stump syndrome (VASS) is a rare condition that can cause posterior circulation ischemic stroke due to occlusion of the ipsilateral vertebral artery (VA) orifice, resulting in blood flow stagnation and embolus formation. Although there is no established treatment for this condition, we observed 3 cases of VASS out of 326 acute ischemic stroke cases at a single institution from April 2021 to October 2022. Despite the best possible antithrombotic treatment, all 3 patients had recurrent ischemic strokes. One patient underwent drug-eluting stenting of the VA orifice to relieve occlusive flow. The other 2 patients received coil embolization, which resulted in the disappearance of their culprit collateral flow. None of the patients had recurrent ischemic strokes after endovascular intervention. Based on our observations, stenting and coil embolization are effective methods for preventing future recurrences of VASS.

Case report: Retrograde endovascular recanalization of vertebral artery occlusion with non-tapered stump via the deep cervical collateral

Introduction

Vertebral artery (VA) occlusive disease is the major cause of posterior circulation ischemic stroke. Endovascular recanalization has been reported as a feasible treatment for patients with symptomatic VA occlusion refractory to optimal medical therapy. However, VA occlusion with non-tapered stump exhibits a low technique success rate when treated by antegrade endovascular therapy because of increased difficulty in passing the guidewire into the occluded segment. Herein, we presented a novel endovascular approach to recanalize chronically occluded VA with a non-tapered stump using a retrograde method via the deep cervical collateral, which has not been reported before.

Case presentation

The present case was a patient with VA ostial occlusion with non-tapered stump and distal severe stenosis of the left VA who had recurrent posterior circulation transit ischemic attacks under optimal medical therapy. CT angiography demonstrated proximal non-tapered occlusion and distal severe stenosis of the left VA, and that the right VA did not converge with the left VA into basilar artery. Endovascular treatment was recommended and performed on this patient. However, antegrade endovascular recanalization of the left VA origin occlusion failed because the micro guidewire was unable to traverse the occluded segment. Fortunately, robust collateral from the deep cervical artery to the V3 segment of the left VA developed, in which we advanced the micro guidewire to the V3 segment of the left VA and reversely passed the micro guidewire through the occluded segment. Then, the occlusion and stenosis of the left VA were successfully resolved with angioplasty and stenting. After the procedure, the patient reported no neurological symptoms under medical therapy during 3-month follow-up.

Conclusion

Antegrade endovascular recanalization of VA occlusion with a non-tapered stump is a challenge. The retrograde endovascular method via the cervical collateral may be an alternative for this type of VA occlusion, which requires further exploration.

Comprehensive classifications for the endovascular recanalization of vertebral artery stump syndrome

Background

and purpose: To share our single-center vertebral artery stump syndrome (VASS) treatment experience and assess the role of comprehensive classification based on anatomic development, proximal conditions, and distal conditions (PAD).

Materials and methods

Data were retrospectively collected from patients who underwent endovascular thrombectomy (EVT) at the Stroke Center of the First Hospital of Jilin University between January 2016 and December 2021. Among patients with acute ischemic stroke in the posterior circulation, those with acute occlusion of the intracranial arteries and occlusion at the origin of the vertebral artery confirmed by digital subtraction angiography were selected. The clinical data were summarized and analyzed.

Results

Fifteen patients with VASS were enrolled in the study. The overall success rate of surgical recanalization was 80%. The successful proximal recanalization rate was 70.6%, and the recanalization rates for P1, P2, P3, and P4 were 100%, 71.4%, 50%, and 66.67%, respectively. The mean operation times for the A1 and A2 types were 124 and 120 ​min, respectively. The successful distal recanalization rate was 91.7%, and the recanalization rates for types D1, D2, D3, and D4 were 100%, 83.3%, 100%, and 100%, respectively. Five patients experienced perioperative complications (incidence rate: 33.3%). Distal embolism occurred in three patients (incidence rate: 20%). No dissection or subarachnoid hemorrhage occurred in any patient.

Conclusion

EVT is a technically feasible treatment for VASS, and comprehensive PAD classification can, to a certain extent, help initially estimate the difficulty of surgery and provide guidance for interventional procedures.

Vertebral artery stump syndrome: A 7-year follow-up case report

Vertebral artery stump syndrome is rare, but one of the most important causes of posterior circulation stroke. To our knowledge, no optimal treatment for vertebral artery stump syndrome has been established, and there are no reports of long-term follow-up. We describe a 69-year-old man with vertebral artery stump syndrome who attended our hospital because of vertigo. Magnetic resonance imaging detected right cerebellar infarcts. Digital subtraction angiography revealed severe stenosis (functional obstruction) at the origin of the right vertebral artery, with distal antegrade collateral flow from the deep cervical artery. We started him on argatroban and cilostazol, but symptoms recurred after 1 month. We changed from cilostazol to aspirin and clopidgrel, then terminated aspirin 1 month after recurrence. He continued on clopidgrel, and follow-up after 7 years showed no recurrence, including asymptomatic lesions.

Endovascular vertebral artery orifice angioplasty for the prevention of acute ischemic stroke following vertebral artery stump syndrome

Background:

Vertebral artery stump syndrome (VASS) involves repeated acute ischemic stroke (AIS) in the posterior circulation following vertebral artery (VA) orifice occlusion. The presence of VA orifice occlusion makes endovascular thrombectomy (EVT) difficult to achieve and leads to posterior circulation stroke with unfavorable functional outcomes. Here, we report a case of endovascular VA orifice angioplasty for the right VA pseudo-occlusion to prevent AIS following VASS pathology.

Case Description:

In a 76-year-old man presenting with dizziness, angiography revealed right pseudo-occluded VA at the origin concomitant with the left VA occlusion. The posterior circulation depended on the right VA through collateral flow to the distal portion. Prophylactic endovascular VA angioplasty for the right pseudo-occluded VA at the orifice was achieved to prevent AIS with tandem lesions. In the present case, endovascular VA angioplasty can prevent acute embolic stroke in the posterior circulation following EVT-resistant VASS pathology.

Conclusion:

Clinicians should be aware that EVT is not easy in AIS following VASS due to access difficulties and the treatment strategy should be carefully considered.

Retrograde recanalisation for vertebral artery stump syndrome: a case report

Vertebral artery stump syndrome (VASS) is a rare disease associated with a posterior circulation stroke after vertebral artery origin occlusion. We have herein presented a case of VASS that was effectively treated with endovascular intervention using retrograde recanalisation and the mechanism of VASS in our patient was thought to be a thrombus formed by stagnating flow.

A Case Series and Literature Review of Vertebral Artery Stump Syndrome

Purpose

Stump syndrome refers to cerebral ischaemic symptoms caused by an embolus from a previously occluded ipsilateral artery that occludes a down-stream artery. It can be divided into two types: carotid stump syndrome and vertebral artery stump syndrome (VASS). At present, there is limited clinical experience with VASS. We aimed to propose a more precise diagnostic standard for VASS, and to share our experience with handling this condition.

Materials and Methods

We retrospectively collected data of patients who were treated with endovascular thrombectomy in the stroke centre of the First Hospital of Jilin University from January 2016 to March 2020. After screening patients with posterior-circulation acute ischaemic stroke, we selected patients who had an acute occlusion of an intracranial artery in the context of a previously occluded ipsilateral vertebral artery origin, as confirmed by digital subtraction angiography.

Results

Eleven patients met our inclusion criteria. Nine patients achieved recanalization of both extracranial and intracranial occluded arteries, one patient had modified thrombolysis in cerebral infarction grade 3, and eight patients had grade 2b. Residual stenosis of recanalized intracranial arteries was less than 30% in all cases, while three patients had embolism of distal arteries. No dissection or subarachnoid haemorrhage occurred. Two patients didn't reach vascular recanalization. Among the nine patients with recanalized artery, four had a 90-day modified Rankin Scale score ≤ 3 (favourable outcome), and four patients died; As for the two non-recanalized patients, one had a mRS score of 5 and one died.

Conclusion

VASS is a clinical syndrome caused by embolic occlusion of a distal intracranial artery occluded ipsilateral extracranial vertebral artery. Antegrade blood flow from the collateral vessels, distal embolic occlusion and mild or no residual stenosis of the occluded intracranial artery after recanalization are notable features of this clinical event. Endovascular thrombectomy may be effective for treating VASS.

Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome

Background:

Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin.

Case Description:

The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy.

Conclusion:

Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.

Microsurgical Treatment Strategy of Vertebral Artery Fusiform Aneurysm-From the Standpoint of Hemodynamic Integrity and Perforator Preservation

During treatment of vertebral artery (VA) fusiform aneurysms, it is critical to preserve peripheral perforators and anterograde blood flow of the VA and to reduce hemodynamic load to the contralateral VA. Even in the era of endovascular treatment, there are still many benefits to using microsurgical treatments with appropriate clip application and preservation of the perforators around the aneurysm, in conjunction with various bypass techniques. The ideal microsurgical technique involves reconstructive clipping that obliterates the aneurysm but preserves anterograde blood flow of the VA, followed by isolation of the aneurysm and VA reconstruction. If these two methods are unavailable, proximal clipping of the aneurysm combined with flow-augmentation bypass to the distal branch can be considered as an alternative surgical management. We discuss the microsurgical treatment of unruptured VA fusiform aneurysms in our surgical cases on the basis of a review of the current literature.

Percutaneous transluminal angioplasty for suspected vertebral artery stump syndrome

Vertebral artery stump syndrome is a rare disease associated with a posterior circulation stroke after vertebral artery origin occlusion. However, few reports have addressed its management. We herein present a case involving a patient with vertebral artery stump syndrome who underwent successful intravascular intervention. We also present a literature review of previous cases of this rare disease. The present case involved a 91-year-old man with acute onset of vertigo and disturbance of consciousness. Diffusion-weighted imaging showed an acute ischaemic stroke in the bilateral cerebellar hemispheres. Magnetic resonance angiography revealed left vertebral artery origin occlusion. Angiography detected a nearly occluded left vertebral artery site, with distal antegrade collateral flow via the deep cervical artery at the C6 level. We observed intravascular stasis at the proximal end of the left vertebral artery via the collateral flow. We performed percutaneous transluminal angioplasty towards the occluded left vertebral artery site. The flow from the left vertebral artery was significantly improved. This is the first report of percutaneous transluminal angioplasty performed for vertebral artery stump syndrome. Although vertebral artery stump syndrome has a high risk of recurrence and a poor prognosis, endovascular intervention showed a better outcome than pharmacotherapy in our patient. However, such cases are rare and further investigations are needed.

Evaluation for Vertebral Artery Injury with Cervical Dislocated Fracture and Optimal Treatment before Reduction

Objective

Cervical dislocated fractures frequently cause vertebral artery injury (VAI), which, in turn, propagates the thrombus at the site of injury. Cerebral embolism due to a thrombus after the reduction of dislocation leads to a poorer neurological outcome. Therefore, we investigated the outcome of treatment for cervical dislocated fractures and the usefulness of parent artery occlusion (PAO) before reduction.

Methods

Eight patients with cervical dislocated fractures with a locked facets treated at our hospital between January 2018 and December 2020 were evaluated. We retrospectively examined patient characteristics and clinical outcomes.

Results

Among the eight patients, two were injured at C4/5, four at C5/6, and two at C6/7. All patients had locked facets. Four patients had bilateral dislocation, while the others had unilateral dislocation. Two patients with unilateral dislocation had ipsilateral vertebral artery occlusion (VAO), while the other six did not. Both patients with VAO underwent PAO to prevent cerebral embolism before reduction. The six patients who did not have VAI underwent reduction without preprocedural treatment. No cerebral ischemic complications were observed. One patient died due to paralysis of the respiratory muscles caused by spinal cord injury but the remaining seven recovered well.

Conclusion

PAO before reduction for cervical dislocated fractures with VAO may be effective in preventing cerebral embolism after reduction.

Vertebral Artery Stump Syndrome Due to Chronic Complicated Aortic Dissection

BACKGROUND

Vertebral artery (VA) stump syndrome arises when thrombi of an occluded proximal VA propagate to the brain and cause posterior circulation strokes. This phenomenon has been described in limited reports to date.

CASE DESCRIPTION

A 39-year-old man with a remote history of endovascular repair of a type B aortic dissection experienced type Ia endoleak causing expansion of the false lumen associated with the dissection. This required combined open debranching and endovascular reconstruction of the thoracic aortic arch. He experienced recurrent posterior circulation strokes 6 months postoperatively. The left VA origin was occluded and remained sequestered to the proximal subclavian artery, in continuity with the false lumen of the dissection. We suspected the aortic dissection extended into the VA and caused the occlusion, while pressure from the false lumen propelled thrombi from the occluded VA stump into the posterior circulation. Repeat imaging shortly after symptom onset showed spontaneous recanalization of the VA. Open surgical ligation of the proximal left VA led to symptom resolution.

CONCLUSIONS

We describe a unique mechanism of VA stump syndrome due to VA occlusion and pressure waves from an aortic dissection and present the first report of VA stump syndrome treatment by surgical exclusion of the VA.

A thread of hope for successful revascularization for acute embolic basilar artery occlusion due to miserable vertebral artery stump syndrome. A technical report

Acute basilar artery occlusion (BAO) is associated with major morbidities and a high mortality rate. The prevalence of acute BAO is 10.4% among patients treated with thrombectomy for acute large vessel occlusion. Vertebral artery stump syndrome (VASS) reportedly causes ischemic stroke with tandem occlusions as vertebral artery (VA) origin occlusion and BAO. The pathogenesis of ischemic stroke due to VASS can be attributed to thrombi or emboli. Acute embolic BAO due to VASS accounted for 2 of 25 cases (8.0%) of BAO treated using thrombectomy between April 2014 and May 2019 in our registry. VASS must be considered as one cause of BAO. With the initial Magnetic resonance angiography on arrival, it is difficult to distinguish between BAO due to simple cardiogenic embolus and due to embolus caused by VASS rapidly. In patients suffering from acute embolic BAO due to VASS, the presence of VA origin occlusion makes endovascular therapy (EVT) difficult to perform. Here, we report consecutive cases of thrombectomy for acute embolic BAO due to VASS, showing markedly different outcomes. VA origin occlusion severely limits the technical options for EVT. Visualization or conjecture of the origin of both or dominant VAs conceivably offers the possibility of successful EVT and may allow good outcomes.

Vertebral Artery Stump Syndrome

Carotid stump syndrome is a well-documented embolic source for ischemic stroke. However, few cases have been reported of a similar condition - termed vertebral artery stump syndrome - which affects the posterior circulation after vertebral artery origin occlusion. We herein report a case of infarction of the right superior cerebellar artery and left posterior inferior cerebellar artery territories due to vertebral artery stump syndrome. In this interesting case, a turbulent flow at the distal side of the vertebral artery occlusion was captured on ultrasonography, and was identified as the probable mechanism of vertebral artery stump syndrome.

Recanalization of symptomatic vertebral ostial occlusion in patients with acute or subacute stroke

SUMMARY

Vertebral artery recanalization in symptomatic stenosis/occlusion remains controversial, as no definite evidence exists regarding this topic. There are only a few reports regarding the feasibility and safety of recanalization in the first segment of the vertebral artery with atherosclerotic vertebral ostial occlusion. We report our experience treating first segment occlusion in 8 patients and present a balloon protection technique used to reduce the thromboembolic burden during the stent placement procedure. The outcome at 3 months showed an mRS ≤2 except for a patient with a poor initial status with basilar artery occlusion. Revascularization of a rather long first segment occlusion is technically feasible and can be safely performed by use of embolic protection methods.

Anticoagulation therapy for vertebral artery stump syndrome

There are very few reports describing the presence of a stump embolism after vertebral artery occlusion. We describe three patients who presented with posterior circulation ischemic strokes after vertebral artery occlusion. These patients were successfully treated with anticoagulation therapy without surgical or endovascular treatment.