Endovascular reconstruction of vertebral artery occlusion prior to basilar thrombectomy in a series of six patients presenting with acute symptomatic basilar thrombosis

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.

Management of posterior circulation tandem occlusions in acute ischemic stroke: Recanalize the dominant vertebral artery with priority

PURPOSE

To illustrate the characteristics of acute ostial vertebral artery (VA) and basilar artery (BA) tandem occlusions. The endovascular treatment strategy for ostial VA-BA tandem occlusion was reported.

MATERIALS AND METHODS

We conducted a retrospective analysis of patients with ostial VA-BA tandem occlusion who underwent endovascular treatment in our center between November 2018 and February 2022. We preferred to recanalize the dominant vertebral artery with priority. The imaging characteristics, treatment strategy, clinical outcomes, and complications were analyzed.

RESULTS

In total, 9 patients with ostial VA-BA tandem occlusion were enrolled in this study. All the VA-BA tandem occlusion was caused by acute occlusion of the dominant VA. Endovascular revascularization was performed through the occluded dominant VA in 8 patients and was performed through contralateral non-dominant VA in 1 patient. Successful recanalization (mTICI 2b/3 grade) was achieved in all 9 patients, and 5 patients (55.5%) achieved functional independence with a mRS score of 0-2 at 90 days.

CONCLUSIONS

In this case series, the occurrence of ostial VA-BA tandem occlusions was mainly caused by acute occlusion of the dominant VA. Endovascular revascularization of ostial VA-BA tandem occlusions through occluded dominant VA was feasible and recommended.

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.

Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy

The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.

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.

Tandem Lesions of the Vertebrobasilar System Treated by Thrombectomy and Vertebral Artery Stenting: A Case Report

Objective

There are few reports on endovascular treatment of tandem lesions in the posterior circulation and no consensus on treatment strategies has been reached. We report a case of tandem lesions of basilar artery occlusion and vertebral artery stenosis treated by thrombectomy and vertebral artery stenting.

Case Presentation

We present the case of a 73-year-old man who developed consciousness disorder and tetraplegia. Head and neck CTA revealed tandem left vertebral artery stenosis and basilar artery occlusion. The patient was treated using a reverse technique, which involves performing thrombectomy first and then vertebral artery stenting, along with Carotid Guardwire PS. Postoperative impairment of consciousness and improvement of tetraplegia were achieved.

Conclusion

The reverse technique combined with Carotid Guardwire PS may be a useful treatment strategy for tandem lesions in the posterior circulation.

Outcome and recanalization rate of tandem basilar artery occlusion treated by mechanical thrombectomy

BACKGROUND

Tandem basilar artery occlusions (tBAO) are defined as concomitant basilar artery and extracranial dominant vertebral artery occlusions. The prognosis of such tBAO treated by mechanical thrombectomy (MT) has been scantly reported. The purpose of our study was to compare the safety and effectiveness of MT for patients with tBAO compared to those with non-tandem basilar artery occlusions (ntBAO).

PATIENTS AND METHODS

Retrospective analysis of a database of patients who underwent MT at two academic centres. All patients treated for BAO were retrieved. Patients with tBAO, defined as a concomitant BAO and extracranial vertebral artery (VA) occlusion or severe stenosis ≥70% (V1 or proximal V2 segment) were compared with patients with ntBAO.

RESULTS

A total of 15 patients with tBAO and 74 patients with ntBAO were enrolled. Successful reperfusion (modified thrombolysis in cerebral infarction score ≥2b) was obtained in 73.3% versus 90.5% (OR = 0.29, 95%CI: 0.07-1.15), good clinical outcome (3-months modified Rankin scale ≤2) was reached by 26.7% versus 32.4% (OR = 0.76; 95% CI: 0.24-2.63) and mortality at 3-months was 46.7% versus 31% (OR = 1.94; 95%CI: 0.63-6) of patients with tBAO versus ntBAO, respectively. Two patients (13.3%) with tBAO and three (4%) with ntBAO had symptomatic intracranial haemorrhage (OR = 3.64; 95% CI: 0.55-24).

CONCLUSION

Mechanical thrombectomy for patients with tandem basilar artery occlusion tends to be associated with lower rates of successful reperfusion and good clinical outcome, and higher rate of mortality. Larger multicentre studies are warranted to better precise the proper selection and management of such patients.

Endovascular Treatment for Vertebrobasilar Artery Tandem Occlusion Beyond 24 Hours From Onset of Stroke-Case Report

We report a case in which endovascular treatment (EVT) was performed for vertebral and basilar artery (VA and BA) tandem occlusion beyond 24 hours from onset of stroke. A 78-year-old man was admitted to our institution with dysarthria and disturbance of gait. MRI revealed occlusion of the BA with acute ischemic change in bilateral cerebellum and brain stem. At 36 hours after onset and 30 hours after administration, EVT was performed because of deteriorating neurological symptom. Successful revascularization was achieved with percutaneous transluminal angioplasty for VA and thrombectomy for BA occlusion. The neurological symptoms were improved in postoperative course.

Posterior circulation tandem occlusions: Classification and techniques

BACKGROUND

Posterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited.

METHODS

We conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019.

RESULTS

Of 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%.

CONCLUSION

Endovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions.

Analysis of Treatment Outcome After Endovascular Treatment in Different Pathological Subtypes of Basilar Artery Occlusion: a Single Center Experience

The current study aimed to evaluate whether patients with different pathologic subtypes of basilar artery occlusion (BAO) stroke could affect the clinical outcome after receiving endovascular treatment (EVT). A total of 187 consecutive patients with acute BAO receiving endovascular treatment (EVT) from January 2012 to July 2018 at the Beijing Tiantan Hospital were recruited in this study. The patients were categorized into three groups: embolism without vertebral artery (VA) steno-occlusion (group 1), in situ atherosclerotic thrombosis (group 2), and embolism from tandem VA steno-occlusion (group 3). Among the 187 patients, 4 patients with embolic combined with ICAS and 1 patient with tandem VA steno-occlusion combined with ICAS were excluded. Of the remaining 182 patients (153 men and 29 women; mean age, 60 years), 43 (23.6%) had embolism without vertebral artery (VA) steno-occlusion (group 1), 116 (63.7%) showed in situ atherosclerotic thrombosis (group 2), and 23 (12.6%) had embolism from tandem VA steno-occlusion (group 3). Overall, successful recanalization (modified thrombolysis in cerebral infarction grade 2b or 3) was achieved in 95.3%, 86.2%, and 60.9% in groups 1, 2, and 3, respectively. The favorable outcome (90-day modified Rankin scale score, 0-3) in the three groups was 51.2%, 52.6%, and 30.4%, respectively. Mortality was higher in group 3 (47.8%) as compared with groups 1 (16.3%) (p = 0.009) and 2 (17.2%) (p = 0.004). Embolism from tandem VA steno-occlusion (group 3) seems to be associated with a lower rate of recanalization and significantly higher rate of mortality as compared with another pathological mechanism of BAO.

Mechanical Thrombectomy for Tandem Vertebrobasilar Stroke: Characteristics and Treatment Outcome

Background and Purpose- Tandem vertebrobasilar strokes are not well-known causes of posterior circulation stroke. The purpose of this study was to investigate the characteristics and outcome of mechanical thrombectomy in patients with tandem vertebrobasilar stroke. Methods- Acute basilar artery occlusion patients with tandem vertebral artery (VA) stenosis/occlusion who underwent mechanical thrombectomy were retrospectively analyzed. Concomitant tandem VA steno-occlusion was defined as severe stenosis/occlusion of the extracranial VA with impaired flow. Clinical/angiographic characteristics, recanalization rate, procedure time, and clinical outcome were evaluated with comparisons according to the treatment strategy. Results- Tandem vertebrobasilar occlusion was identified in 24.6% (55 of 224) of the acute basilar artery occlusion patients. Overall successful recanalization and good clinical outcome was achieved in 87.2% (48 of 55) and 30.9% (17 of 55) of the patients. There were no significant differences in procedure time, recanalization rate, and clinical outcome in comparisons of the VA access route selection or angioplasty of the tandem VA lesion. Two patients developed short-term recurrent basilar artery occlusion when angioplasty of the tandem VA lesion was not performed. Good clinical outcome was more likely with lower baseline National Institutes of Health Stroke Scale score (odds ratio, 0.87 [95% CI, 0.787-0.961]; P=0.006) and short onset-to-recanalization time (odds ratio, 0.993 [95% CI, 0.987-0.999]; P=0.03). Conclusions- Tandem vertebrobasilar occlusion may be a frequent pathological mechanism of posterior circulation stroke. Good outcome may be achieved by strategic choice of the access route and selective angioplasty of the tandem VA lesion.

The "distal-to-proximal" strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience

PURPOSE

Data on posterior circulation tandem occlusions in acute ischemic stroke are scarce: recognition may be challenging and little is known about optimal treatment strategy. We report our endovascular treatment strategy for posterior circulation tandem occlusion.

METHODS

Consecutive patients with posterior circulation tandem occlusions in our centre were enrolled retrospectively. The preferred strategy was "distal-to-proximal" strategy, which means opening the distal occlusion first followed by treatment of the proximal pathology. The imaging characteristics, treatment strategy, clinical outcomes, and complications of patients with posterior circulation tandem occlusions were analyzed.

RESULTS

In total, 21 patients with posterior circulation tandem occlusions were enrolled in the study, which accounted for 23.6% of patients with posterior circulation stroke in our centre. The mean age was 60 years (range 32 to 80), and median pre-procedure NIHSS score was 28 (interquartile range: 13-31). Eighteen patients (85.7%) had vertebrobasilar artery tandem occlusions and 3 (14.3%) had basilar artery to basilar artery tandem occlusions. All distal occlusions were successfully recanalized (modified TICI 2b/3). Two (9.5%) of the proximal lesions were not treated. A total of 57.1% of the patients had stents implanted on the proximal occlusions. The rate of mRS 0-3 at 3 months was 57.1% and the mortality rate was 19.0%.

CONCLUSION

In patients with acute ischaemic stroke caused by posterior circulation tandem occlusions, we favor "distal-to-proximal" strategy based on the positive results in this small series. Nevertheless, a more extensive study is required to explore the optimal treatment strategy further.

Recanalization of Tandem Vertebrobasilar Occlusions with Contralateral Vertebral Occlusion or Hypoplasia via either Direct Passage or the SHERPA Technique

Introduction

Tandem vertebral ostial disease with acute intracranial vertebrobasilar occlusion with contralateral vertebral occlusion or hypoplasia presents a unique challenge to the interventionalist.

Methods

The authors queried a prospectively maintained institutional endovascular database from August 2013 to June 2018 for cases of endovascularly treated acute tandem vertebrobasilar occlusions in the presence of contralateral vertebral occlusive disease or hypoplasia. Demographic and presentation data, the technique, results, and clinical outcome were extracted.

Results

Tandem recanalization was attempted and achieved in 5 patients with a thrombolysis in cerebral infarction (TICI) 3 result in 4 patients and a TICI 2c result in 1 patient. To facilitate effective manual aspiration thrombectomy for the tandem basilar occlusion, performed in all cases in 1 or 2 passes, the Neuron^TM MAX sheath was advanced into the V2 after Dotter or balloon angioplasty of the diseased origin. In cases where the origin cannot be crossed/visualized, the Synchro Helper to Evaluate via Retrograde Passage an Arterial origin (SHERPA) technique, entailing the passage of a microwire retrograde via the hypoplastic contralateral vertebral artery was utilized to delineate the vertebral ostium (n = 2 cases). All but 1 patient had substantial improvement in the National Institutes of Health Stroke Scale score after the procedure.

Conclusion

Recanalization of tandem vertebrobasilar occlusions with contralateral occlusion or hypoplasia is feasible. Intracranial recanalization is facilitated by the passage of a long 6F sheath into V2, and retrograde delineation of an occluded vertebral origin with a microwire may serve as a crucial adjunct.

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.

Endovascular treatment of tandem occlusions in vertebrobasilar stroke: technical aspects and outcome compared with isolated basilar artery occlusion

Background and purpose

Acute basilar artery occlusion (BAO) is a devastating disease with a high rate of mortality and morbidity, and early recanalization is crucial to achieve a good prognosis. The best treatment strategy for BAO combined with a proximal stenosis (tandem occlusion) is not yet clear. Our study aimed to evaluate whether and how vertebrobasilar tandem occlusions can be treated effectively and safely compared with isolated BAO.

Materials and methods

Fifty-two patients with acute vertebrobasilar occlusive stroke treated with mechanical thrombectomy were identified in a prospective database from March 2010 to September 2016. We retrospectively analysed the clinical, technical, and functional outcomes of the patients.

Results

Of the 52 patients, 15 presented with a tandem occlusion, 14 with a single intracranial occlusion due to an underlying stenosis, and 23 with a single embolic BAO. Successful recanalization was achieved in all of the patients with tandem occlusions (modified Thrombolysis in Cranial Infarction 2b/3) and in 35 of 37 patients with a single BAO (with and without stenosis). A favourable outcome was achieved (modified Rankin Scale ≤2) in 8 of the 15 patients with a tandem occlusion compared with 4 of the 14 patients with a single BAO with underlying stenosis and 5 of the 23 patients with isolated embolic BAO (p=0.18).

Conclusions

We suggest that endovascular treatment of vertebrobasilar tandem occlusions is safe and feasible, with a high rate of good outcome.

Endovascular revascularisation of acute tandem vertebrobasilar artery occlusion: seven case series with literature reviews

Background

The outcome of acute ischaemic stroke due to tandem vertebrobasilar artery occlusion was poor. Endovascular revascularisation may be a positive approach for acute basilar artery occlusion combined with vertebral ostium stenosis or occlusion. We reported seven patients with acute vertebrobasilar tandem occlusion by using angioplasty or stenting for proximal lesion and thrombectomy for distal occlusion.

Materials and methods

Consecutive patients with acute tandem vertebrobasilar artery occlusion at two centres were included in this study. We retrospectively analysed the clinical, technical and functional outcomes of the patients.

Results

From March 2016 to March 2017, seven patients were included. The mean age and National Institute of Health Stroke Scale score at admission was 57 years and 22, respectively. A reverse approach was used in five patients. The Thrombolysis in Cerebral Infarction score 2b-3 was acquired in all patients. There were no procedural complications. The modified Rankin Scale score was 1–2 for three patients and 4 for one patient at 3 months. Three patients died at 3 months of follow-up.

Conclusions

Endovascular revascularisation may be feasible for acute tandem vertebrobasilar artery occlusion, and more researches are needed.

Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations-Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke

Patients suffering from acute atherothrombotic occlusion of the proximal vertebral artery (VA) and concomitant basilar artery (BA) occlusion present a grim prognosis. We describe our experience in the endovascular recanalization of tandem vertebrobasilar occlusions using endovascular techniques. The BA was accessed through the normal VA (clean-road) or the occluded, thrombotic VA (dirty-road), and stentriever-based thrombectomy was performed using antegrade or reverse revascularization variants. Seven patients underwent successful stentriever-assisted mechanical thrombectomy of the BA and five sustained concomitant VA revascularization. Stroke onset to endovascular intervention initiation (time-to-treatment) ranged from 4.5-13hours (mean 8.6). In two of seven patients, the BA occlusion was approached with a 'clean-road' approach via the contralateral VA; in five of seven patients, a 'dirty-road' approach via the occluded VA was used. Mean time-to-recanalization was 66minutes (range 55-82). There were no perforations, iatrogenic vessel dissections, or other technical complications. Four patients presented mild-to-moderate disability (modified Rankin Scale [mRS] 0-3) at 3months, one remained with moderate-to-severe disability (mRS 4), and two patients died on days 9 and 23 after their strokes. Follow-up ranged from 6-45months (mean 24months). In selected patients with acute VA-BA occlusion, stentriever-based thrombectomy performed through either the patent or the occluded VA, may be feasible, effective, and safe. Clinical outcomes in these patients seem to equipoise the neurological outcome of patients with successful revascularization for isolated BA occlusion. This unique pair of occlusions confirms the role of VA ostium stenosis as a cause of vertebrobasilar stroke.