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

Last update on February 16, 2024

Explore this clinical case featuring a 51-year-old male presenting with left-sided shoulder/neck pain for a week, acute onset left-sided weakness, left visual field cut, and right PCA p2-3 occlusion. Delve into the endovascular management of the recurrent large vessel occlusion from vertebral artery dissection refractory to medical treatment, and uncover the unique challenges associated with VA dissection.

Case presentation

Clinical Presentation

  • 51-year-old male
  • Left sided shoulder/neck pain for 1 week
  • Acute onset left sided weakness, left visual field cut
  • Right PCA (Posterior Cerebral Artery) p2-3 occlusion
  • Administered IV (tissue plasminogen activator) in the Emergency Room
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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

 

Thrombectomy #1 – Right PCA

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Medical Management

  • Admission to ICU,q1 hour neuro checks
  • Plan to load with Aspirin/Plavix pending 24 hr post tPA CT scan
  • Brain MRI also ordered
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Thrombectomy #2

  • Following afternoon – sudden onset right visual field cut
    • Left PCA p1 segment occlusion on CTA (Computed Tomography Angiography)
    • Full reperfusion post aspiration + stentriever thrombectomy, single pass
    • Microvention 6 French Sofia
    • Medtronic Solitaire stentriever 4 mm x 40 mm
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Thrombectomy #2
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Thrombectomy #2

 

Medical Management

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  • Brain MRI negative for hemorrhagic conversion
  • Loaded with Aspirin / Plavix
  • Exam reassuring post-extubation
  • Left vertebral artery takedown scheduled next morning with Stryker Target XL soft coils

 

Thrombectomy #3

  • Same day overnight
    • Neuro exam change – decreased level of alertness, progressed to becoming obtunded
    • Basilar artery occlusion confirmed on CTA
  • Taken emergently for thrombectomy
    • Full reperfusion – single pass aspiration
    • Microvention 6 French Sofia catheter
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Thrombectomy #3
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
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