Basilar artery clot retrieval for stroke due to traumatic vertebral artery injury

Patient presentation

• 27-year-old male patient
• Motorbike accident
• No previous medical history
• Alert, no ischemic symptom
• Quadriplegia

Case

• Cervical CT: Transverse foramen fracture
• MRI: T2 high signal intensity in the C3-5 spinal cord
• CT angiography: Left VA stenosis or occlusion at C3-6 Right VA hypoplasia

• Transport to the angiography suite after MRI.
• Sudden deterioration → coma

Angiography

• Left VA: complete occlusion
• Right VA: hypoplastic
• Basilar artery: no filling

Intervention

• Clot retrieval with stent retriever

Clinical course

• Immediately regained consciousness.
• Additional ischemic lesions on MRI after the intervention.
• Cervical spine surgery the next day.

MRI before deterioration

MRI after intervention

In this case…

• On admission: left VA dissection with ≥ 25% luminal narrowing + right VA hypoplasia asymptomatic
• After 1st MRI: left VA occlusion+ right VA hypoplasia distal migration of the thrombus comatose
• Possible clot migration during transport of the patient

• Microcatheter navigation through the traumatic dissection was relatively smooth.
• Heparinization before surgery, antiplatelet therapy after surgery.
• Residual stenosis is under observation, probable stenting in the future.

Traumatic VA injury

• No consensus about the management of traumatic VA injury.
• Accompanying injury: more difficult management
• In our department
  • Unilateral VA dissection/occlusion: proximal coil embolization
  • Bilateral VA occlusion: antithrombotic therapy or bilateral coil occlusion
  • Bilateral VA dissection: antithrombotic therapy

• For cervical spine injury patients, screening of arterial injury with CTA is recommended.
• When the patient deteriorates, occlusion or distal clot migration can be happening.
• Immediate endovascular clot retrieval is safe and useful.
• Before and after the surgery, antithrombotic therapy can be protective against stroke.