Clinical outcome of patients with acute posterior circulation stroke and bilateral vertebral artery occlusion

Abstract

Background and introduction: Patients presenting with posterior circulation acute ischemic events are occasionally noted to have occlusion of bilateral vertebral arteries with basilar artery blood flow entirely dependent from the anterior circulation. There is limited data about prognosis of such patients in literature.

Methods: Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion (including contra-lateral hypoplastic vertebral artery without contribution to the basilar artery system) were identified prospectively from two academic centers. Data including clinical presentation, medical management, angiographic findings, recurrent events and outcome were collected and reported.

Results: A total of 4 patients presenting with acute ischemic events in the posterior circulation were identified to have bilateral vertebral artery occlusion at our center. One additional patient had a vertebral artery occlusion and a contra-lateral hypoplastic vertebral artery. In the functional evaluation of the blood flow with catheter angiography, the basilar artery was filling from the anterior circulation, with no antegrade flow from bilateral vertebral arteries injection in all 5 patients. Patients were treated with anti-platelets (n=4) or started on anti-coagulation after failing anti-platelet therapy (n=2). All patients had recurrent ischemic stroke with new ischemic lesions proven by diffusion weighted images on MRI within 2 to 70 days after the initial event.

Conclusion: Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion are at high risk of having early recurrent ischemic events. Reestablishment of the antegrade vertebro-basilar blood flow through endovascular re-canalization might be an option to decrease stroke recurrence in selected patients with acute posterior circulation stroke and bilateral vertebral artery occlusion.

Keywords: bilateral; ischemic stroke; prognosis; vertebral artery occlusion.

Cerebral angiograms: Figure 1a: Bilateral selective injection showing occlusion of the V3 segment of left and right VA. Figure 1b: Selective injection of left ICA showing patency of the left posterior communicating artery with retrograde filling of the basilar artery and terminal branches.

Cerebral angiograms: Figure 2a: Lateral view of the cranium from selective injection in the right proximal ICA demonstrates robust filling of the post circulation including basilar artery from the distal tip to the origin of the Left PICA. Figure 2b: Selective injection in the right VA showing occlusion of the intracranial right VA immediately after the origin of the right PICA.

Cerebral angiograms: Figure 3a: Cerebral Angiogram showing lateral view of injection of the left subclavian artery showing occlusion of the proximal left vertebral art with distal reconstruction of the left distal V2 & V3 segment via ascending cervical collaterals. Figure 3b: Cerebral angiogram lateral view of selective injection in the right VA showing hypoplastic right VA that functionally ends up in right PICA with faint filling of the distal basilar and SCA.

Cerebral angiograms: Figure 4a: Cerebral angiogram selective injection in the right VA showing a hypoplastic right vert that ends up in PICA. Figure 4b: Cerebral angiogram selective injection in the left VA showing occlusion of the left VA at the distal V-3 segment.

Cerebral angiograms: Figure 5a: Lateral view of selective injection of the Lt VA showing severe stenosis (near occlusion) of the proximal intra-cranial left VA after the origin of the Left PICA. Figure 5b: Lateral view of selective injection of the Lt VA showing complete re-canalization of the left intra-cranial VA with good distal flow throughout the basilar artery, bilateral AICA & SCAs after successful intra-cranial angioplasty and stent placement.