|Year : 2020 | Volume
| Issue : 2 | Page : 193-196
Emergency vertebrobasilar stenting in recurrent medial medullary ischemic stroke
Rahul Pathak, Imran Gafoor, Vishal Kumar, Saket Jethani
Department of Neurology and Critical Care Medicine, Ramkrishna Care Hospital, Raipur, Chhattisgarh, India
|Date of Submission||30-Sep-2019|
|Date of Decision||12-Nov-2019|
|Date of Acceptance||10-Dec-2019|
|Date of Web Publication||17-Jun-2020|
Dr. Rahul Pathak
Department of Neurology and Critical Care Medicine, Ramkrishna Care Hospital, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Intracranial stenting and angioplasty have been used widely to treat atherosclerotic symptomatic vascular stenosis when conventional medical therapy fails to eliminate ischemic symptoms. We describe a case report of middle-age diabetic male with endovascular stent deployment for the treatment of atherosclerotic vertebrobasilar artery stenosis with acute recurrent medial medullary ischemic stroke. Application of a drug-eluting stent coronary stent without previous balloon dilatation resulted in vessel reopening and good clinical improvement. Emergency primary intracranial stent deployment can be technically feasible and improve the outcome in acute vertebrobasilar artery occlusion whenever indicated.
Keywords: Basilar artery, deep venous thrombosis, drug-eluting stent, dual antiplatelets therapy, intracranial stents
|How to cite this article:|
Pathak R, Gafoor I, Kumar V, Jethani S. Emergency vertebrobasilar stenting in recurrent medial medullary ischemic stroke. Indian J Vasc Endovasc Surg 2020;7:193-6
|How to cite this URL:|
Pathak R, Gafoor I, Kumar V, Jethani S. Emergency vertebrobasilar stenting in recurrent medial medullary ischemic stroke. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jul 30];7:193-6. Available from: https://www.indjvascsurg.org/text.asp?2020/7/2/193/286913
| Introduction|| |
Patients with the vertebrobasilar occlusive disease are at high risk for stroke that leads to the worst neurological symptoms. Although an unfavorable clinical outcome is found in as many as two-thirds of patients with vertebrobasilar ischemic stroke, technically successful thrombolysis and stenting of vertebrobasilar artery occlusion are associated with good clinical outcomes.
We report our experience with stenting without previous dilatation of symptomatic basilar artery with recurrent acute atherosclerotic ischemic lesions refractory to medical therapy.
| Case Report|| |
A 45-year-old middle-aged male was admitted to the neurointensive care unit with dysarthria, asymmetric quadriparesis, and difficulty in deglutination for 2 days. Serum antinuclear antibody and viral markers were negative. Electrocardiogram and echocardiogram were within the normal limits. His National Institutes of Health Stroke score was 14. His magnetic resonance imaging (MRI) of the brain and magnetic resonance angiography (MRA) showed acute diffuse restriction in upper medulla [Figure 1] and [Figure 2], while MRA showed focal tight stenosis in vertebrobasilar junction with diffuse atherosclerotic plaque in the vertebro bailar junction and distal vertebral artery. Right vertebral artery was absent with the right fetal posterior cerebral artery [Figure 3].
|Figure 1: Acute lacunar diffusion restriction in medial upper medulla in DWI|
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|Figure 2: Acute lacunar diffusion restriction in medial upper medulla in ADC|
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He was treated with anticoagulants and dual antiolatelates. On the 10th day of admission, his condition deteriorated. He became tachypnic, drowsy, and developed flaccid quadriparesis. After intubation, his MRI brain showed acute diffuse restriction in bilateral medial medulla [Figure 4]. MRA showed tight focal stenosis in vertebrobasilar artery [Figure 5].
|Figure 5: Magnetic resonance angiography-focal critical stenosis in vertebro-basilar artery junction|
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Cerebral angiography was performed a few hours later after aggravation of symptoms showed focal critical stenosis in the vertebrobasilar artery with diffuse atherosclerotic plaque in that region [Figure 6] and [Figure 7].
|Figure 6: Focal stenosis in vertebrobasilar ar tery junction with atherosclerotic plaque AP view in DSA|
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Therefore, emergency stenting was planned to restore distal flow and to prevent recurrent stroke. Loading dose of dual antiplatelet therapy was given. Heparin 5000 IU was given with intravenous (IV) route. A guide catheter neuron max 6 fr was positioned with the support of guidewire in distal V2 segment in appropriate position with 1000 IU/h continuous heparin flush. Traxcess microwire 0.014 was navigated slowly across the lesion and positioned in the left P2 segment. Coronary balloon mounted – 3 mm × 12 mm (Yukon choice) drug-eluting stent was positioned to cover entire lesion without prior balloon angioplasty. The pressure elevation was performed by two atmospheres in each step. Balloon was inflated slowly not more than 15 s with a gradual increment of atmosphere up to the third attempt not under sizing the stent in comparison to vessel diameter. Angiogram was repeated for the next 30 min to check dissection, thrombus formation or flow restriction. After half an hour, no thrombus or dissection was seen in the angiogram of the left vertebral artery [Figure 8], [Figure 9], [Figure 10], [Figure 11]. IV heparin was continued for 7 days to prevent thromboembolic complications and then for deep-vein thrombosis prophylaxis.
|Figure 8: Poststenting images with complete recanalization in fluoroscopy DSA|
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|Figure 10: Poststenting images with complete recanalization in lateral view|
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The patient was extubated on the 3rd day of the procedure. He became conscious and was able to follow simple verbal commands. Extraocular movements were full in all directions and were able to move the tongue in, out, and side by side. Mild dysarthria and deglutination were there. After 2 weeks, his speech improved with power Grade 3/5 on the right and 2/5 on the left side. His modified Rankin scale was 4 at the time of discharge. Ecosprin 325 mg and clopidogrel 75 mg was continued for secondary prophylaxis. On follow-up, angiography showed normal filling of basilar artery with stent in situ [Figure 12].
| Discussion|| |
The prognosis with basilar artery atherothrombotic occlusion is worst with more than two-third mortality rate if not treated. Even with aggressive medication and local intraarterial fibrinolytic treatment, death is still a probable outcome for such cases. Distal basilar artery occlusion is embolic, usually while mid-third and proximal basilar artery occlusion occurs due to thrombus formation in pre-existing atherosclerotic disease. Proximal and mid-third basilar occlusion has the worst prognosis as compared to distal basilar occlusion.
Currently, for both angioplasty and stenting, for high-grade (70%) stenosis refractory to medical therapy is indicated for intervention, while others also advise intervention for asymptomatic high-grade (70%) stenosis. Intraplaque dissection, plaque dislodgment, vessel recoil with restenosis, perforator occlusion, and excessive in-stent neointimal growth rarely formation of an intrastent aneurysm or stent infection are endovascular complications.
Other indications for stenting are cases refractory to balloon angioplasty, because of calcified lesions, bailout stenting for dissection after angioplasty and symptomatic vertebrobasilar artery restenosis after previous angioplasty.
Several cases have been reported worldwide of endovascular stent treatment in the atherosclerotic basilar artery; however, there are only a few reports of stent application as rescue therapy in symptomatic acute recurrent medial medullary ischemic infarct with acute high-grade basilar artery stenosis.
In our case, the patient developed recurrent medial medullary ischemic infarct despite of aggressive medication with underlying severe stenosis of the proximal basilar artery. This patient has strong likelihood of restenosis if narrowing was not relieved timely. We applied the stent without previous dilatation. This decreases the risk of intimal dissection and distal embolization by plaque prolapse.
Therefore, emergency basilar stenting without balloon angioplasty is technically feasible and effective as a rescue treatment with tight basilar stenosis.
Our case is probably the first case worldwide of emergency basilar stenting without angioplasty with acute bilateral recurrent medial medullary syndrome with severe vertebro-basilar atherosclerotic stenosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yu W, Jiang WJ. Stenting for intracranial stenosis: Potential future for the prevention of disabling or fatal stroke. Stroke Vasc Neurol 2018;3:140-6.
Gomez CR, Misra VK, Liu MW, Wadlington VR, Terry JB, Tulyapronchote R, et al
. Elective stenting of symptomatic basilar artery stenosis. Stroke 2000;31:95-9.
Kim BM, Suh SH, Park SI, Shin YS, Chung EC, Lee MH, et al
. Management and clinical outcome of acute basilar artery dissection. AJNR Am J Neuroradiol 2008;29:1937-41.
Ihn YK, Baik JH, Park YH. Emergency rescue primary stenting for atherosclerotic basilar artery occlusionwith acute thrombosis – A case report. Interventional Neuroradiology 2005;11:69-73.
Eberhardt O, Naegele T, Raygrotzki S, Weller M, Ernemann U. Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: Case series and review of the literature. J Vasc Surg 2006;43:1145-54.
Spreer J1, Els T, Hetzel A, Arnold S, Klisch J, Huppertz HJ, et al
. Primary stenting as emergency therapy in acute basilar artery occlusion. Neuroradiology 2002;44:791-5. [Epub 2002 Jul 20].
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]