Endovascular Treatment May Be Effective in Preventing Recurrence of Ischemic Stroke in Vertebral Artery Stump Syndrome: A Case Series

Abstract

Vertebral artery stump syndrome (VASS) is a rare condition that can cause posterior circulation ischemic stroke due to occlusion of the ipsilateral vertebral artery (VA) orifice, resulting in blood flow stagnation and embolus formation. Although there is no established treatment for this condition, we observed 3 cases of VASS out of 326 acute ischemic stroke cases at a single institution from April 2021 to October 2022. Despite the best possible antithrombotic treatment, all 3 patients had recurrent ischemic strokes. One patient underwent drug-eluting stenting of the VA orifice to relieve occlusive flow. The other 2 patients received coil embolization, which resulted in the disappearance of their culprit collateral flow. None of the patients had recurrent ischemic strokes after endovascular intervention. Based on our observations, stenting and coil embolization are effective methods for preventing future recurrences of VASS.

Keywords: Acute ischemic stroke; Recurrence; Stents; Vertebral artery; Vertebral artery stenosis.

Fig. 1.

Various findings of case 1 (an 81-year-old male). On days 1 (A), 5 (B), and 8 (C), diffusion-weighted imaging revealed the presence of recurring ischemic stroke of the superior cerebellar artery area. Based on the magnetic resonance angiography findings (D), the right vertebral artery (VA) appears to be the posterior inferior cerebellar artery end. Therefore, it was not reasonable to sacrifice the left VA. The left VA ostium was occluded, and antegrade blood flow was detected through the deep cervical artery at the C3/4 level (arrow) based on frontal (E) and lateral (F) views. VA occlusion was recanalized with angioplasty and stenting, as confirmed by frontal (G) and lateral (H) views. No recurring ischemic events were reported following the endovascular treatment procedure.

Fig. 2.

Various findings of case 2 (a 62-year-old male). On days 1 (A), 7 (B, C), and 9 (D), diffusion-weighted imaging revealed the presence of recurring ischemic strokes. Based on magnetic resonance angiography findings (E), the left vertebral artery (VA) appeared well-developed. The right VA ostium was occluded, and antegrade blood flow was detected through the ascending cervical artery at the C3/4 level (arrow) and occipital artery at the C1 level (arrow head), based on frontal (F) and lateral (G, H) views. Coil embolization in the inflow zone of the collateral arteries at the C1/2 level was performed via contralateral VA (I). The stagnancy in blood flow disappeared, as confirmed by frontal (J) and lateral (K, L) views. No recurring ischemic events were observed following the endovascular treatment procedure.

Fig. 3.

Various findings of case 3 (a 66-year-old male). On days 1 (A), 4 (B), and 6 (C), diffusion-weighted imaging revealed the presence of recurring ischemic strokes. Based on the posterior view (D) of computed tomography angiography, the left vertebral artery appeared occluded from the orifice and the deep cervical artery was well-developed. Antegrade blood flow was detected through the deep cervical artery at the C1/2 level (arrow) and ascending cervical artery at the C2/3 level (arrow head), based on frontal (E) and lateral (F) views. Coil embolization was performed at the distal end of the thrombus via the deep cervical artery (G). The stagnancy in blood flow disappeared, as confirmed by the lateral (H) view. No recurring ischemic events were observed following coil embolization.