Recurrent posterior circulation infarcts secondary to vertebral artery external compression treated with endovascular deconstruction

Abstract

When multiple, recurrent infarcts occur in spite of maximal medical management, the level of suspicion for atypical vascular injury should be heightened. We present a case of a patient who presented with recurrent posterior circulation infarcts despite optimized medical management. On imaging, he was found to have external anatomical vertebral artery muscular and/or osseous compression leading to repetitive vascular injury and strokes. Recurrent intimal injury and vertebral artery to intracranial emboli despite anticoagulation and subsequent dual antiplatelet therapy necessitated definitive operative management. Surgical bypass, external surgical decompression, reconstructive endovascular, and deconstructive endovascular techniques were carefully considered. A deconstructive endovascular approach was chosen as the least morbid option. The use of endovascular plugs such as a microvascular plug provides a quick and effective means of achieving a therapeutic parent artery occlusion in lieu of traditional coil occlusion. Although reserved as a last resort, parent artery occlusion can be a viable option to treat recurrent strokes, particularly in a nondominant vertebral artery.

Keywords: Bow Hunter’s syndrome; Recurrent posterior circulation strokes; endovascular deconstruction; extravasal compression; microvascular plug (MVP); vertebral artery dissection.

Figure 1.

(a) Axial computed tomography angiography (CTA) with contrast showing compression of the right vertebral artery (VA) between the C5 transverse process (thin arrow) and the longus colli muscle (thick arrow) with external compression and a luminal filling defect (arrowhead) (b) Coronal CTA showing compression of the right VA by the longus colli muscle (thin white arrow) against the C5 transverse process (deep and laterally).

Figure 2.

(a) Digital subtraction angiography (DSA) and (b) unsubtracted angiogram from right vertebral artery injection showing deviation and luminal irregularity (curved arrow). Complete occlusion (black arrow) of the vessel on DSA (c) after placement of two microvascular plugs; radio-opaque markers (white arrows) seen on magnified unsubtracted (d) microcatheter angiogram.

Figure 3.

Computed tomography angiography oblique coronal curved reformation three months after treatment, showing filling of the vertebrobasilar circulation from the dominant left vertebral artery with retrograde filling of the proximally occluded right vertebral artery (arrowhead), supplying the posterior inferior cerebellar artery (not shown).