Acute Basilar Artery Stroke with Bilateral Vertebral Artery Occlusion Is Not Untreatable: Revascularization of the Vertebral Artery Through the Thyrocervical Trunk with a Transradial Snare-Assisted Technique and Stenting Followed by Basilar Trunk Stentriever Thrombectomy and Posterior Fossa Decompressive Craniectomy with an Unexpectedly Favorable Outcome

Abstract

The natural history of acute basilar artery occlusion (ABAO) is devastating. These occlusions carry the highest mortality and morbidity among strokes attributable to intracranial large vessel occlusions (LVOs) and the beneficial effects of intravenous thrombolysis are modest in these patients. Recanalization rates following mechanical thrombectomy are lower in patients with ABAO than those with anterior circulation occlusions, and procedure times are longer. Nevertheless, recanalization is achieved in many patients and favorable outcomes are achieved; thus, every effort should be made to obtain rapid and complete arterial recanalization. This chapter illustrates an example of this premise. However, revascularization is only one crucial part of major vertebrobasilar stroke’s more complex, multidisciplinary treatment. In patients who develop massive cerebellar edema due to posterior circulation stroke, suboccipital decompressive craniectomy is an efficient and frequently life-saving procedure. It must be considered on a case-by-case basis according to clinical status and findings on neuroradiological imaging.

A 63-year-old man was admitted to the Emergency Department after being found unconscious at his home. He had described feeling generally unwell, with dizziness and blurred vision throughout the previous morning. The patient was last seen normal, although with these complaints, 16 h before admission. On admission, he was in a deep coma with pupils equal and sluggishly reactive, absent right corneal reflex, decerebrate-opisthotonic posturing, and asymmetric tetraparesis. He was intubated and ventilated and transferred for tomographic evaluation. Cranial CT confirmed signs of advanced microvascular brain disease and a hyperdense basilar artery. CT angiography showed a tortuous ascending aorta, dolichoectatic supra-aortic trunks, advanced atherosclerosis, and bilateral vertebral artery (VA) and basilar trunk occlusions. The patient was immediately transferred to the angiography suite for endovascular treatment.

Repeated attempts to gain access to the basilar trunk through the occluded dominant right and hypoplastic left VAs failed. We then catheterized the ascending cervical artery that reconstituted the occluded right VA at V2 and successfully crossed the V1 occlusion retrograde. After gaining radial access, we snared the microguidewire that crossed V1 at the subclavian artery (SA) and forced antegrade navigation of the snare microsystem into the VA lumen. We then proceeded to angioplasty and stenting of the origin of the right VA. Stent retriever-assisted basilar artery embolectomy with a 6F guiding catheter allowed the basilar trunk and major branches to be recanalized. However, three distal emboli traveled to the posterior inferior cerebellar artery (PICA), anterior inferior cerebellar artery (AICA), and superior cerebellar artery (SCA). Four hours after the intervention, anesthesia was interrupted, and the patient regained consciousness with only left hemiparesis. We had planned to extubate him, but he progressively deteriorated. CT depicted cerebellar edema that was collapsing the fourth ventricle. The patient was then brought to the operating room for posterior fossa decompressive craniectomy and ventriculostomy. After an uneventful postoperative course, the patient was finally extubated on postoperative day 3 and transferred for rehabilitation on day 8. At his 30-day evaluation, he showed only residual gait ataxia and mild left hemiparesis. At 90 days, his modified Rankin Scale score (mRS) was 1.

Revascularization of the basilar trunk is of paramount importance, and every effort should be made to accomplish this objective. This unusual case describes a poorly explored endovascular route to the vertebrobasilar system via the ascending cervical artery and the use of a snare to connect catheter systems navigated through different vascular approaches. Endovascular revascularization was complemented with decompressive craniectomy with excellent clinical results. Alternative routes for vertebrobasilar revascularization are the main topic of this chapter.