The dilemma of treating vertebrobasilar dolichoectasia

Abstract

Vertebrobasilar dolichoectasia (VBD) is a common phenomenon among people over 50 years old, and the related clinical expressions are varied. One of our VBD patients presented with brainstem infarction initially, received low molecular weight heparin treatment, and developed rupture of the dolichoectasia segment. Another patient with a similar-sized VBD experienced recurrent brainstem infarction three times over 2 years, despite higher bleeding tendency and long-term antiplatelet treatment. The third patient with a smallersized VBD, had left hemiplegia and received intravenous recombinant tissue plasminogen activator within 3 h, totally recovered with no lesions detected on brain Magnetic Resonance Imaging (MRI). The pathophysiology of VBD is unique, its prevalence and risks of ischemic stroke and intracranial hemorrhage both increase as the degree of arterial dolichoectasia extends, making the strategy of management quite a challenge. The best management of VBD is controlling arterial hypertension and following up with image studies regularly to detect the early extension of VBD degree.

Keywords: basilar artery occlusion; ischemic stroke; non-saccular intracranial aneurysm; subarachnoid hemorrhage.; vertebrobasilar dolichoectasia.

Figure 1

Brain computed tomography of the first patient performed 2 days after onset shows vertebrobasilar dolichoectasia with hyperdense basilar signs.

Figure 2

Computed tomography angiography of the first patient performed 2 days after onset reveals dolichoectasia of the left vertebral artery to basilar artery, and multiple fusiform aneurysms at bilateral middle cerebral artery.

Figure 3

Brain computed tomography of the first patient performed 4 days after onset demonstrates massive brainstem hemorrhage.

Figure 4

Brain computed tomography of the second patient performed in April 2006 shows vertebral deforming event indentation to left pons.

Figure 5

Brain computed tomography of the second patient performed in May 2007 shows hypodense lesion over left pons.

Figure 6

Brain diffusion weighted-magnetic resonance imaging of the second patient performed in October 2007 demonstrates acute right pons infarction.

Figure 7

Brain computed tomography of the second patient performed in October 2007 shows same-sized vertebral deforming event indentation to left pons.

Figure 8

Brain diffusion weighted-magnetic resonance imaging of the second patient performed in February 2008 shows right pons ischemic stroke, without difference of vertebral deforming event character compared to previous study.

Figure 9

Brain computed tomography of the third patient performed 1 h after symptoms onset shows thrombus formation within basilar artery; there's also mild compression on medullo-cervical junction by basilar.

Figure 10

Brain magnetic resonance angiography performed after patient's totally recovery shows vertebrobasilar dolichoectasia.