Percutaneous transluminal angioplasty for suspected vertebral artery stump syndrome

A case of vertebral artery stump syndrome treated by parent artery occlusion via collateral anastomosis

The treatment for vertebral artery stump syndrome (VASS) remains controversial. Here, we report a case of VASS in which cervical vertebral artery (VA) occlusion was performed. A 35-year-old man was admitted for left VA cerebellar infarction caused by left cervical VA dissection with severe stenosis on angiography, and was administered aspirin (100 mg/day). One month after discharge, the patient experienced recurrent stroke with cerebellar infarction. Digital subtraction angiography revealed that the origin of the left VA was occluded and that the VA received antegrade and retrograde flow via the left ascending and deep cervical arteries. The patient was diagnosed with a retrograde flow-induced thrombosis and recurrent embolic stroke. Planned parent artery occlusion (PAO) was performed using a left radial approach under local anesthesia. The patient did not experience stroke recurrence after the procedure. PAO via collateral anastomosis is an option for recurrent stroke treatment when anastomosis via the muscle branch is well developed.

Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options

INTRODUCTION

Stump syndrome is defined as a clinical syndrome resulting from a distal intracranial vessel embolic stroke due to an extracranial vessel occlusion. Similar to the anterior circulation, the recurrence of ischemic strokes in territories supplied by the posterior circulation in the presence of vertebral artery occlusion is termed Vertebral Artery Stump Syndrome (VASS).

MATERIAL AND METHODS

We conducted a literature review, identifying 72 patients with transient ischemic attacks (TIAs) or ischemic strokes attributed to VASS, according to Kawano criteria. We categorized all patients in two groups focusing on the therapeutic management those who underwent primary medical treatment and those who received endovascular or surgical treatment either in acute or chronic phase.

RESULTS

In the anticoagulant therapy group, only 1 patient had a stroke recurrence. Among the 4 on antiplatelets, all had recurrences, but 3 benefited from switching to anticoagulants or endovascular therapy. In the endovascular therapy group, worse outcomes were linked to acute large vessel occlusion. Endovascular treatment of the vertebral artery, in a chronic phase, was explored in literature for recurrent TIAs or minor strokes suggesting that this could be a viable therapeutic alternative when medical treatment failed in preventing recurrence of ischemic stroke.

CONCLUSIONS

Some studies suggest that anticoagulant medical therapy may be beneficial for VASS and endovascular therapy has also been reported for selected patients. However, data on treatment outcomes and prognosis are still underreported, making treatment decisions challenging. Randomized Controlled Trials are needed to establish the optimal treatment approach.

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.

Endovascular treatment of acute basilar artery occlusion caused by vertebral artery stump syndrome: A clinical analysis of 37 cases

Introduction

Acute basilar artery occlusion (ABAO) caused by vertebral artery stump syndrome (VASS) has a low incidence and is always underestimated. Due to the occlusion of the origin of the vertebral artery (VA), it is often combined with basilar artery (BA) endovascular diseases or non-dominant contralateral vertebral artery, making the endovascular treatment (EVT) challenging to implement.

Objective

This article focuses on whether EVT and two interventional route options could bring clinical benefits to this group of patients: basilar artery thrombectomy through the occluded lateral vertebral artery and implementing revascularization of the occluded vertebral artery (dirty-road-path); thrombectomy through the non-occluded lateral vertebral artery (clean-road-path).

Methods

We collected six cases of acute embolic basilar artery occlusion (ABAO) due to VASS from January 2020 to December 2021 at our hospital and retrospectively analyzed 31 patients previously reported in the literature and applied statistical analysis to investigate the treatment options and clinical prognosis of these patients.

Results

The clean-road-path surgical protocol was applied in 4 of 37 patients, the dirty-road-path protocol was applied in 29 patients, and 4 patients did not recanalized the basilar artery. By statistical analysis we found that successful recanalization of the basilar artery was clinically significant in reducing the modified Rankin Scale (mRS) scores in these patients, the statistical difference in the benefit of the two surgical protocols was negative. There was a significant positive correlation between preoperative National Institute of Health Stroke Scale (NIHSS) and postoperative 90-day mRS scores.

Conclusion

Endovascular treatment can benefit patients with ABAO due to VASS, and patients with higher preoperative NIHSS scores are more vulnerable to getting a poor prognosis. Comparison between the two endovascular options did not yield statistically significant results, but the dirty-road-path option may be superior to using the clean-road-path.