Symptomatic Atherosclerotic Non-acute Intracranial Vertebral Artery Total Occlusion: Clinical Features, Imaging Characteristics, Endovascular Recanalization, and Follow-up Outcomes

Background and Objectives: Previous studies on symptomatic atherosclerotic non-acute intracranial vertebral artery total occlusion that was refractory to medical therapy are rare. We aimed to assess the clinical features, imaging characteristics, endovascular treatment feasibility and follow-up outcomes of patients with this condition.

Methods: Data from consecutive patients who had symptomatic atherosclerotic non-acute intracranial vertebral artery total occlusion and underwent endovascular recanalization from February 2016 to April 2020 were retrospectively collected in our prospective database. Clinical, imaging, procedural, and follow-up data were collected and analyzed.

Results: Thirty-one patients, predominantly males, were enrolled in this study. These patients presented with recurrent/progressive stroke in the posterior circulation despite aggressive medical therapy. Angiographic analysis revealed asymmetric vertebral arteries due to unilateral hypoplasia and intracranial vertebral artery total occlusions in the dominant vertebral arteries, which were characterized by long lesion length and high clot burden. Multiple infarctions and perfusion defects in the posterior circulation were demonstrated by diffusion-weighted imaging and arterial spin labeling, respectively. Successful endovascular recanalization was achieved in 87.1% of the patients. Over a median clinical follow-up duration of 11.0 months, 74.1% of patients with successful recanalization achieved favorable clinical outcomes (mRS score ≤2).

Conclusion: Symptomatic atherosclerotic non-acute intracranial vertebral artery total occlusion attributable to hypoperfusion is characterized by recurrent/progressive ischemic events, dominant intracranial vertebral artery total occlusion, long lesion length, and high clot burden. Endovascular recanalization of the dominant intracranial vertebral artery occlusion appears to be a feasible treatment for these patients.

Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: Experience of a single center and review of literature

OBJECTIVE

The optimal treatment of chronic symptomatic total occlusion of the intracranial vertebral artery (ICVA) remains undefined. We report a single-center experience of endovascular recanalization for patients with chronic symptomatic ICVA occlusion who were refractory to medical therapy.

METHODS

From Jan 2009 to Jan 2017, we retrospectively reviewed 14 consecutive patients presenting with recurrent symptoms attributed to the chronic ICVA occlusion. We searched previous literature using PubMed databases during the same period as comparison.

RESULTS

Eleven patients out of 14 presented initial symptoms to intervention less than 90days. The occlusion course was extrapolated on simultaneous two-vessel injection angiography or high-resolution MR imaging (HRMRI) in 13 cases. Nine patients had the occlusion beyond the origin of posterior inferior cerebellar artery (PICA) and 5 had the occlusion proximal to the PICA origin. The technical success rate of recanalization was 85.7% (12/14). Two patients (14.3%, 2/14) had peri-procedural complications: 1 developed TIA and 1 presented with perforator occlusion syndrome. Using the keyword-based search, we identified 6 studies at the same period. A total of 34 patients underwent recanalization with the successful recanalization rate at 94.1%, peri-procedural complication rate at 17.6% and mortality at 2.9%, respectively.

CONCLUSION

Our single-center study illustrated the feasibility and safety of ICVA recanalization. Great care should be taken as revascularization is of high risk. When patient selection, occlusion course and stage as well as neuroimaging evaluation are considered, endovascular recanalization may be a useful therapeutic modality.