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.

A rare association of subclavian steal syndrome with bilateral carotid artery stenosis: a case report

Bilateral carotid artery stenosis in the context of subclavian steal syndrome is an extremely rare finding. We report the case of a 75-year-old woman who presented with a transient ischemic attack. Bilateral internal carotid stenosis associated with left subclavian steal syndrome was diagnosed. Left internal carotid endarterectomy was performed under locoregional anesthesia. Inflation of a blood pressure cuff reversed the neurologic symptoms that appeared after internal carotid clamping. This rarely reported case remains a challenge to diagnose and treat because of its complex mechanisms and multiple risk factors. Our case highlights the importance of the surgical strategy adopted and the need for a good initial assessment.

Cervical dumbbell-type tumor spontaneously shrinking following an ischemic stroke

Background

Asymptomatic cervical dumbbell-type tumors can be incidentally diagnosed. Notably, the chronological changes in the size of these tumors have not been satisfactorily described.

Case Description

A 57-year-old man was clinically followed for an asymptomatic cervical dumbbell-type tumor that had the appearance of a schwannoma on magnetic resonance (MR) images obtained over a 7-year period. Notably, the tumor compressed both the spinal cord and the right vertebral artery. At the end of the 7-year period, the patient sustained a cerebral infarction due to atherosclerosis of the right vertebral artery; the angiogram revealed both atherosclerosis and the tumor compressing the right vertebral artery. After the stroke/ischemic event, the tumor progressively shrunk on MR images obtained for the following 4 years, and the spinal cord compression was similarly relieved.

Conclusion

Here, we report on a 57-year-old man with cervical MR images revealing that a cervical dumbbell schwannoma was progressively compressing both the spinal cord and the right vertebral artery. However, following a cerebral infarction, the tumor underwent spontaneous shrinkage over the next 4 years, thus relieving the compression.

High-Flow Saphenous Vein Graft Bypass from Common Carotid Artery to Vertebral Artery (V2) for the Treatment of Vertebrobasilar Insufficiency Due to Bilateral Vertebral Artery Origin Stenosis

Vertebrobasilar insufficiency (VBI) can lead to devastating brainstem and posterior cerebral infarction without timely treatment.¹ A 56-year-old man with history of hypertension, hyperlipidemia, and diabetes mellitus presented to the clinic with right hemiparesis due to previous left cerebral hemispheric stroke. He also harbored a giant asymptomatic parietooccipital meningioma incidentally diagnosed 2-years ago. Neuroimaging showed old left cerebral infarcts and a tumor that had remained stable in size. Cerebral angiography identified bilateral vertebral artery stenosis near their origin from the subclavian arteries with severe vertebrobasilar insufficiency. There was some collateral flow to the posterior cortex via the internal maxillary and occipital artery branch anastomoses. Despite recommendation, the patient decided to not undergo tumor resection, but opted for a high-flow bypass to the posterior circulation to prevent stroke. We used saphenous vein graft to perform a high-flow extracranial-to-extracranial bypass revascularization of the ischemic vertebrobasilar circulation as demonstrated in the operative video. The patient tolerated the procedure well and was discharged without new deficits 4-days post-op. Most recent follow-up 3-years after surgery revealed a patent bypass graft with no new adverse cerebrovascular events. The tumor remains asymptomatic without change in imaging characteristics. Cerebral bypasses continue to remain useful tools in carefully selected patients for the treatment of complex aneurysms, complex tumors and ischemic cerebrovascular diseases.^2-7 In this report, we demonstrate an extracranial-to-extracranial high-flow bypass to revascularize the posterior cerebral circulation using a saphenous vein graft in a patient with VBI.

Percutaneous transluminal angioplasty and stenting of post-irradiation stenosis of the vertebral artery

BACKGROUND

The outcomes of percutaneous transluminal angioplasty and stenting (PTAS) in patients with medically refractory post-irradiation stenosis of the vertebral artery (PISVA) have not been clarified.

AIM

This retrospective study evaluated the safety and outcomes of PTAS in patients with severe PISVA compared with their radiation-naïve counterparts (non-RT group).

METHODS

Patients with medically refractory severe symptomatic vertebral artery stenosis and undergoing PTAS between 2000 and 2021 were classified as the PISVA group or the non-RT group. The periprocedural neurological complications, periprocedural brain magnetic resonance imaging, the extent of symptom relief, and long-term stent patency were compared.

RESULTS

As compared with the non-RT group (22 cases, 24 lesions), the PISVA group (10 cases, 10 lesions) was younger (62.0 ± 8.6 vs 72.4 ± 9.7 years, P = 0.006) and less frequently had hypertension (40.0% vs 86.4%, P = 0.013) and diabetes mellitus (10.0% vs 54.6%, P = 0.024). Periprocedural embolic infarction was not significantly different between the non-RT group and the PISVA group (37.5% vs 35.7%, P = 1.000). At a mean follow-up of 72.1 ± 58.7 (3-244) months, there was no significant between-group differences in the symptom recurrence rate (0.00% vs 4.55%, P = 1.000) and in-stent restenosis rate (10.0% vs 12.5%, P = 1.000).

CONCLUSION

PTAS of severe medically refractory PISVA is effective in the management of vertebrobasilar ischemic symptoms in head and neck cancer patients. Technical safety and outcome of the procedure were like those features in radiation-naïve patients.

Rotational Vertebral Artery Syndrome (Bow Hunter's Syndrome): A Rare Differential Diagnosis in Patients With Syncope

Syncope is a common symptom in clinical practice. Rotational vertebral artery occlusion syndrome, also referred to as Bow Hunter's syndrome (BHS), is a rare condition associated with syncope and is caused by mechanical occlusion or stenosis secondary to mechanical compression of the vertebral artery during head rotation. BHS is associated with a multifactorial etiology; however, in most cases, this condition is attributed to degenerative changes. A 53-year-old man visited our hospital for the evaluation of fainting and dizziness episodes that occurred when he turned his head. Evaluation as an outpatient in the Department of Neurology showed a positive result on the Frenzel goggle test. Transfemoral cerebral angiography performed at the Department of Neurosurgery revealed stenosis of the proximal right vertebral artery. Complete occlusion of the vertebral artery was observed, and the head was turned to the right. Decompression and fusion were performed, and the contributory lesion was completely removed. Postoperative imaging confirmed complete removal of the spur and sufficient vertebral artery decompression; the patient's symptoms resolved postoperatively.

Vertebral artery stenosis predicts cerebrovascular diseases following radiotherapy for nasopharyngeal carcinoma

PURPOSE

Radiotherapy for nasopharyngeal carcinoma (NPC) may induce cerebrovascular diseases including ischemic stroke and transient ischemic attack (TIA), which can cause severe disability. However, information on the incidence and predictors of cerebrovascular diseases is scarce. This study aimed to estimate the incidence of cerebrovascular diseases following NPC, and attempts to ascertain the predictors of cerebrovascular diseases to facilitate early prevention.

METHODS

We performed a retrospective cohort study on 655 NPC patients who received radiotherapy between 2006 and 2018 in a medical center. This study analyzed the incidence, clinical and imaging presentation of patients with cerebrovascular diseases. Cox proportional hazard model was used to identify risk factors associated with cerebrovascular diseases following radiotherapy.

RESULTS

There were 14 patients who developed an ischemic stroke, and 3 patients developed a TIA after a mean follow-up of 5.8 years. Most ischemic events were from large-artery atherosclerosis (76.5%), and the most common symptom of ischemic stroke was unilateral limb weakness (57.1%). The cumulative incidence of ischemic stroke or TIA 15 years after radiotherapy was 9.1% (95% confidence interval [CI] = 4.7-17.2%). Multivariate Cox regression identified vertebral artery stenosis (HR: 18.341; 95% CI = 3.907-86.100; P < 0.001), atrial fibrillation (HR: 13.314; 95% CI = 1.306-135.764; P = 0.029), and hypertension (HR: 7.511; 95% CI = 1.472-38.320; P = 0.015) as independent predictors of ischemic stroke or TIA.

CONCLUSION

Our study found that NPC patients with vertebral artery stenosis, atrial fibrillation, or hypertension carry a higher risk for ischemic stroke or TIA. Regular assessment of vertebral artery after radiotherapy was suggested.

Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis

Subclavian steal syndrome is a rare phenomenon occurring from retrograde blood flow in the vertebral artery due to proximal stenosis in the subclavian artery. As a result, the arm gets blood supply from the vertebral artery at the expense of the vertebrobasilar system. The patient remains largely asymptomatic until there is an increase demand for blood supply to the arm, resulting in a constellation of symptoms including dizziness, vertigo, blurred vision, diplopia, headache, syncope, postural hypotension, neurologic deficits, and rarely, memory problems. The management approach depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.

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Subclavian steal syndrome with concurrent carotid artery stenosis is only the second documented case, which makes it an extremely rare presentation or frequently unnoticed condition.

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Absence of symptoms does not rule out subclavian steal syndrome with bilateral carotid stenosis and should be considered in the differential in patients with high risk comorbidities with appropriate imaging and physical exam.

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The treatment depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.

Carotid, Vertebral, and Brachiocephalic Interventions

Carotid atherosclerosis most frequently manifests in the proximal internal carotid artery and the common carotid artery bifurcations. Subclavian artery atherosclerosis affects the proximal segments with a relatively higher incidence on the left and becomes clinically important in the presence of vertebrobasilar insufficiency or coronary steal. Atherosclerosis of the vertebral artery can lead to posterior circulation stroke. The authors review the major trials on carotid carotid, brachiocephalic and vertebral artery stenosis along with the various available diagnostic and interventional techniques.

Stent-Assisted Coiling of Pseudoaneurysm After Vertebro-Carotid Transposition: Harmonious Combination of Open and Endovascular Neurosurgical Techniques

BACKGROUND

Most cases of vertebral artery stenosis are treated either conservatively or surgically. When non-conservative treatment is chosen, whether to treat it with open surgery or endovascular intervention remains a topic of divergence. In the setting of endovascular therapy failure, the vertebral to common carotid artery transposition certainly is an appropriate choice to recover the posterior circulation. Like any other open surgery, it is not devoid of soft-tissue-related complications. A pseudoaneurysm following this procedure and at this particular location is a rare but lethal complication and, to the best of our knowledge, has not yet been reported.

CASE DESCRIPTION

We present the case of an 80-year-old man with previous ischemic stroke who presented to the emergency department with aphasia, right-sided weakness, and dysarthria. Invasive imaging revealed right vertebral stenosis and hypoplastic left vertebral artery that failed endovascular therapy. The patient was then treated with a right vertebral to common carotid artery transposition. During follow-up, a pseudoaneurysm was found and treated with a stent-assisted coiling.

CONCLUSIONS

Pseudoaneurysms at the extracranial carotid and vertebral circulation are rare and have potential for deadly outcomes. Despite several treatments available, this anatomical location requires endovascular therapy due to efficacy and promptitude of this treatment. This is an interesting case where the patient's management required open and endovascular procedures. The pseudoaneurysm was a rare complication that, to the best of our knowledge, has not previously been reported. This case is an illustration of complementary work between open surgery and endovascular intervention.

Effect of Endovascular Treatment on Quality of Life in Patients with Recurrent Symptoms Associated with Vertebral, Subclavian, or Innominate Arterial Stenosis

BACKGROUND

Patients with vertebral, subclavian, or innominate arterial stenosis can present with recurrent symptoms that can adversely affect the quality of life (QOL). We aimed at determining the short-term effects of endovascular treatment (ET) on QOL in these patients.

METHODS

European Quality of Life Five Dimension Scale (EQ-5D) utility index and visual analog scale (VAS) were ascertained before and within one month of ET in patients with vertebral, subclavian, or innominate arterial stenosis with recurrent episodes of vertigo, near syncope, and/or ataxia. The EQ-5D utility scores were derived from responses to five questions on EQ-5D questionnaire (-0.109 for the least to 1 for most favorable). The EQ-5D VAS score was obtained by subject's indication of his/her health state on a scale of 0 (worst) to 100 (best).

RESULTS

Angioplasty and/or stent placement was performed in 10 patients for stenosis in extracranial vertebral (n = 6), intracranial vertebral (n = 1), subclavian (n = 2), or innominate artery (n = 1). There was a significant reduction in preprocedure severity [mean ± standard deviation (SD)] of stenosis compared with postprocedure severity (79.9 ± 14.05% vs. 26.4 ± 37.7%, p < 0.001). There was a significant improvement in mean values of EQ-5D VAS postprocedure compared with preprocedure values (72 vs. 57.5, p = 0.018). Minimal important difference (improvement of at least 0.074) on EQ-5D utility index and on VAS (improvement ≥ 10 points) was reported by five and six of 10 patients, respectively.

CONCLUSIONS

Improvement in QOL appears to be an important measure of effectiveness of ET in patients with vertebral, subclavian, or innominate arterial stenosis with recurrent episodes of vertigo, near syncope, and/or ataxia.

Endovascular treatment of symptomatic vertebral artery stenosis: A systematic review and meta-analysis

BACKGROUND

The study aim was to evaluate the safety and efficacy of endovascular treatment (EVT) versus medical treatment (MT) in patients with symptomatic vertebral artery (VA) stenosis.

METHODS

Randomized controlled trials with active and control groups receiving EVT plus MT and MT alone in patients with vertebro-basilar transient ischemic attack (TIA) or stroke and VA stenosis were identified. Primary endpoints included the occurrence of any stroke, any vertebro-basilar stroke, vertebro-basilar ischemic stroke, and vertebro-basilar TIA. Secondary endpoints were myocardial infarction, vascular death, and composite vascular outcome. All endpoints were assessed at short and long-term. Risk ratios (RRs) with 95% confidence intervals (CIs) have been estimated.

RESULTS

Four trials were included involving 370 participants, 194 and 176 for EVT and MT arms, respectively. There was no overall effect of EVT on the occurrence of any stroke [short-term: RR 3.05 (95% CI 0.33-28.49); long-term: RR 0.75 (95% CI 0.40-1.40)], any vertebro-basilar stroke [short-term RR 3.05 (95% CI 0.33-28.49); long-term RR 0.91 (95% CI 0.42-1.99)], vertebro-basilar ischemic stroke [short-term: RR 1.02 (95% CI 0.07-15.88); long-term RR 1.27 (95% CI 0.36-4.50)], vertebro-basilar TIA [short-term: RR 5.00 (95% CI 0.28-90.18); long-term: RR 0.85 (95% CI 0.39-1.81)]. There were no differences across the treatments in any secondary outcome.

CONCLUSIONS

There were no clear-cut benefits or harms for EVT versus MT alone in patients with symptomatic VA stenosis.

Asymptomatic Extracranial Vertebral Artery Disease in Patients with Internal Carotid Artery Stenosis

BACKGROUND

Extracranial vertebral artery disease is seen in patients with internal carotid artery stenosis, although the clinical significance is not well understood.

OBJECTIVE

To determine the prevalence and natural history of extracranial vertebral artery disease in patients with recently symptomatic internal carotid artery stenosis.

METHODS

We analyzed data collected for patients with recently symptomatic internal carotid artery stenosis in the Stent-Protected Angioplasty vs Carotid Endarterectomy trial. We used Cox proportional hazards analysis to compare the relative risk of various endpoints (any stroke, ipsilateral stroke, and death) between the 3 categories of extracranial vertebral artery disease (normal/hypoplastic, moderate/severe stenosis, occlusion) adjusting for age, gender, severity of internal carotid artery stenosis at baseline (<70% and ≥70%), allocated procedure (carotid angioplasty and stent placement or carotid endarterectomy) and hypertension.

RESULTS

Moderate to severe stenosis and occlusion of 1 of both extracranial vertebral arteries were diagnosed in 152 (12.9%) and 57 (4.8%) of 1181 subjects, respectively. Comparing subjects with normal or hypoplastic vertebral artery, there was nonsignificant 30%, 40%, and 50% higher risk of any stroke (hazard ratio [HR] 1.3, 95% confidence interval [CI] 0.7-2.3), ipsilateral stroke (HR 1.4, 95% CI 0.7-2.5), and death (HR 1.5, 95% CI 0.7-3.1) among subjects with moderate to severe vertebral artery stenosis after adjusting for potential confounders.

CONCLUSIONS

There may be an increased risk of stroke and death in patients with symptomatic internal carotid artery stenosis with concurrent asymptomatic extracranial vertebral artery stenosis.

Detection of vessel wall calcifications in vertebral arteries using susceptibility weighted imaging

PURPOSE

Calcification of the brain supplying arteries has been linked to an increased risk for cerebrovascular disease. The purpose of this study was to test the potential of susceptibility weighted MR imaging (SWMR) for the detection of vertebral artery calcifications, based on CT as a reference standard.

METHODS

Four hundred seventy-four patients, who had received head CT and 1.5 T MR scans with SWMR, including the distal vertebral artery, between January 2014 and December 2016, were retrospectively evaluated and 389 patients were included. Sensitivity and specificity for the detection of focal calcifications and intra- and interobserver agreement were calculated for SWMR and standard MRI, using CT as a standard of reference. The diameter of vertebral artery calcifications was used to assess correlations between imaging modalities. Furthermore, the degree of vessel stenosis was determined in 30 patients, who had received an additional angiography.

RESULTS

On CT scans, 40 patients showed a total of 52 vertebral artery calcifications. While SWMR reached a sensitivity of 94% (95% CI 84-99%) and a specificity of 97% (95% CI 94-98%), standard MRI yielded a sensitivity of 33% (95% CI 20-46%), and a specificity of 93% (95% CI 90-96%). Linear regression analysis of size measurements confirmed a close correlation between SWMR and CT measurements (R ² = 0.74, p < 0.001). Compared to standard MRI (ICC = 0.52; CI 0.45-0.59), SWMR showed a higher interobserver agreement for calcification measurements (ICC = 0.84; CI 0.81-0.87).

CONCLUSIONS

For detection of distal vertebral artery calcifications, SWMR demonstrates a performance comparable to CT and considerably higher than conventional MRI.

Hemodynamic assessment and computation on vertebral artery stenosis

Cerebral vascular diseases are associated with cerebral hemodynamic parameter, which is difficult to observe and examine. This paper has proposed a new modeling method based on network and hemodynamics. The harmonic solution to the 18 branches of the circle of Willis is acquired through the plane network. We use this method to explain the development processes of vertebral artery diseases, and the hemodynamic assessment of vertebral artery stenosis have been done to prove this method.

Percutaneous Treatment of Vertebral Artery Stenosis

Endovascular treatment of the ostial and proximal portions of the vertebral artery is a safe and effective technique for alleviating symptoms and improving cerebral blood flow to the posterior circulation. Vertebral artery angioplasty can be performed with high technical and clinical success rates, low complication rates, and durable long-term results. Although restenosis rates range from 0% to 48%, the durability of vertebral artery angioplasty is evidenced by low restenosis rates in multiple large series reported in the literature using multiple treatment options, including balloon angioplasty alone, bare metal stents, and drug-coated stents.

Endovascular treatment of extracranial vertebral artery stenosis

Percutaneous angioplasty and stenting for the treatment of extracranial vertebral artery (VA) stenosis seems a safe, effective and useful technique for resolving symptoms and improving blood flow to the posterior circulation, with a low complication rate and good long-term results. In patients with severe tortuosity of the vessel, stent placement is a real challenge. The new coronary balloon-expandable stents may be preferred. A large variability of restenosis rates has been reported. Drug-eluting stents may be the solution. After a comprehensive review of the literature, it can be concluded that percutaneous angioplasty and stenting of extracranial VA stenosis is technically feasible, but there is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management.