Endovascular Management of Recurrent Large Vessel Occlusion from Vertebral Artery Dissection Refractory to Medical Treatment

Clinical Presentation

Thrombectomy #1

• Agitated, combative – intubated for procedure
• Right radial access
  • Right PCA p2-3 segment occlusion on angiogram
  • Full reperfusion post single-pass aspiration
  • Penumbra 3max catheter

Medical Management

Thrombectomy #2

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Medical Management

Thrombectomy #3

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Important Considerations

• Natural history of vertebral artery dissections favorable
• Medical management first-line
  • tPA
  • DAPT (Dual Antiplatelet Therapy) vs anticoagulation
• Importance of neurological exam to prompt stat repeat imaging

Unique Challenges to VA Dissection

• Approach to vertebral artery dissections with LVO different than carotid dissection
  • Caliber of contralateral vertebral artery
  • Infarct burden in posterior circulation
  • Greater risk for hemorrhagic conversion
  • Lack of embolic protection filter during stenting

Treatment Considerations

• Endovascular options
  • Reconstruction – presence of a channel
    • Dominant vertebral artery
    • Risk of further emboli by crossing through clot
    • Rist of extension if entry into false lumen
  • Sacrifice – complete occlusion
    • Non-dominant vertebral artery
    • Risk of hypoperfusion
    • Treatment antegrade vs retrograde
• When to commit to intervention
  • Deem failure of medical management
  • Versus whether to perform it at same time as thrombectomy