Mechanical Thrombectomy and Parent Artery Occlusion for Acute Basilar Artery Occlusion Due to Vertebral Fracture and Artery Dissection: A Case Report

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Abstract

Objective

Basilar artery occlusion (BAO) secondary to traumatic vertebral artery (VA) dissection caused by vertebral fracture is a rare cause of acute ischemic stroke, and optimal management, such as antithrombotic agents, surgical fixation, and parent artery occlusion (PAO), has been controversial. We report a case in which mechanical thrombectomy and PAO were performed for a BAO due to right VA dissection caused by a transverse foramen fracture of the axis vertebra.

Case Presentation

A patient in her 80s suffered from a backward fall, and a neck CT revealed a fracture and dislocation of the right lateral mass of the axis and a compressed transverse foramen. The patient was instructed to admit and to remain in bed rest; however, she suddenly lost consciousness the following day. The CTA revealed right VA occlusion and BAO; therefore, the patient underwent mechanical thrombectomy and the BAO was successfully reperfused but the VA stenotic dissection remained. PAO of the right VA was performed on the fifth day after the accident to prevent BAO recurrence.

Conclusion

Mechanical thrombectomy is an effective treatment for BAO caused by VA dissection, and PAO may contribute to the prevention of stroke recurrence.

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Most cited references 20

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Blunt cerebrovascular injuries: does treatment always matter?

Clint W Sliker, F Lui, S Boswell … (2008)

Blunt cerebrovascular injuries (BCVI) have become an increasingly recognized entity. Stroke as a result of these injuries can have devastating consequences. Optimal screening criteria, diagnostic imaging, and therapy for BCVIs have not been elucidated. Our institution began to apply liberal screening criteria using a whole-body scanning protocol with multidetector computed tomographic (WB-MDCT) scans to diagnose these injuries. The purpose of this study is to describe a single institution's large experience in patients with BCVI in an effort to provide insight into the diagnosis and management of these injuries. All patients with a BCVI admitted to the R Adams Cowley Shock Trauma Center during a 30-month period were included in this study. Choice of diagnostic evaluation and treatment regimens were at the discretion of the treating attending physician. Review of medical records and all relevant radiographic studies were retrospectively performed for the purposes of this study. During the study period, there were 12,667 patients admitted to the R Adams Cowley Shock Trauma Center. There were 147 patients identified with 200 carotid or vertebral artery injuries. The incidence of BVCI was 1.2%. Mortality was 13%. Anatomic injury risk factors for BCVI (major facial fractures, skull base fractures, cervical spine fractures or spinal cord injury, or traumatic brain injury) were found in only 78%. Major thoracic injury was found in 63% of patients with carotid artery injuries and cervical spine fractures or spinal cord injury was found in 74% of patients with vertebral artery injuries. The initial screening test employed was a WB-MDCT in 96% of patients of which 84% detected a BCVI. Treatments included endovascular therapy (22%), antiplatelet medications (36%), anticoagulation (10%), and combination therapy with antiplatelet agents and anticoagulation (18%). Thirty percent received no therapy, primarily due to contraindications from concomitant injuries. There were 18 (12%) patients who had a stroke. Of these patients, 8 (44%) had evidence of infarction at admission, 6 were diagnosed within 72 hours, and 4 were diagnosed after 1 week. Stroke-related mortality was 50%, whereas clinical follow-up after hospital discharge demonstrated only one patient with disability as a result of infarction. Of 10 patients who did not have stroke at admission, 3 were fully treated, 5 had specific contraindications to therapy, and 2 had no or false-negative imaging before infarction. Stroke rates for untreated patients were 25.8% and patients treated with any therapy had a stroke rate of 3.9% (p = 0.0003). Radiographic follow-up >1 month after injury demonstrated improvement in over 50% of patients. BCVIs are not infrequent after blunt trauma. These injuries occur even in the absence of classically described risk factors. Liberal screening with WB-MDCT incorporates detection of these injuries into the initial diagnostic evaluation. Stroke occurs in a substantial number of patients and carries a very high mortality. However, nearly one third of patients with BCVI are not candidates for therapy. Treatment does reduce the risk of infarction in patients with BCVI, but strokes, when they occur, are not preventable.

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Optimizing screening for blunt cerebrovascular injuries.

Walter L Biffl, Sophie E. Moore, K E Brega … (1999)

The recognition that early diagnosis and intervention, prior to ischemic neurologic injury, has the potential to improve outcome following blunt cerebrovascular injuries (BCVI), led to a policy of aggressive screening for these injuries. The resultant epidemic of BCVI has created a dilemma, as widespread screening is impractical. We sought to identify independent predictors of BCVI, to focus resources. Cerebral arteriography was performed based on signs or symptoms of BCVI, or in asymptomatic patients with high-risk mechanisms (hyperextension, hyperflexion, direct blow) or injury patterns. Logistic regression analysis identified independent predictors. A total of 249 patients underwent arteriography; 85 (34%) had injuries. Independent predictors of carotid arterial injury were Glasgow coma score < or =6, petrous bone fracture, diffuse axonal brain injury, and LeFort II or III fracture. Having one of these factors in the setting of a high-risk mechanism was associated with 41% risk of injury. Of patients with cervical spine fracture, 39% had vertebral arterial injury. Patients sustaining high-risk injury mechanisms or patterns should be screened for BCVI. In the face of limited resources, screening efforts should be focused on those with high-risk predictors.

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Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography.

Walter L Biffl, Sophie E. Moore, Al Aly … (2002)

To assess the impact of routine follow-up arteriography on the management and outcome of patients with acute blunt cerebrovascular injuries (BCVI). During the past 5 years there has been increasing recognition of BCVI, but the management of these lesions remains controversial. The authors previously proposed a grading system for BCVI, with grade-specific management guidelines. The authors have noted that a significant number of injuries evolve within 7 to 10 days, warranting alterations in therapy. A prospective database of a regional trauma center's experience with BCVI has been maintained since 1990. A policy of arteriographic screening for BCVI based on injury mechanism (e.g., cervical hyperextension) and injury patterns (e.g., cervical and facial fractures) was instituted in 1996. A grading system was devised to develop management protocols: I = intimal irregularity; II = dissection/flap/thrombus; III = pseudoaneurysm; IV = occlusion; V = transection. From June 1990 to October 2001, 171 patients (115 male, age 36 +/- 1 years) were diagnosed with BCVI. Mean injury severity score was 28 +/- 1; associated injuries included brain (57%), spine (44%), chest (43%), and face (34%). Mechanism was motor vehicle crash in 50%, fall in 11%, pedestrian struck in 11%, and other in 29%. One hundred fourteen patients had 157 carotid artery injuries (43 bilateral), and 79 patients had 97 vertebral artery injuries (18 bilateral). The breakdown of injury grades was 137 grade I, 52 grade II, 32 grade III, 25 grade IV, and 8 grade V. One hundred fourteen (73%) carotid and 65 (67%) vertebral arteries were restudied with arteriography 7 to 10 days after the injury. Eight-two percent of grade IV and 93% of grade III injuries were unchanged. However, grade I and II lesions changed frequently. Fifty-seven percent of grade I and 8% of grade II injuries healed, allowing cessation of therapy, whereas 8% of grade I and 43% of grade II lesions progressed to pseudoaneurysm formation, prompting interventional treatment. There was no significant difference in healing or in progression of injuries whether treated with heparin or antiplatelet therapy or untreated. However, heparin may improve the neurologic outcome in patients with ischemic deficits and may prevent stroke in asymptomatic patients. Routine follow-up arteriography is warranted in patients with grade I and II BCVIs because most of these patients (61% in this series) will require a change in management. A prospective randomized trial will be necessary to identify the optimal treatment of BCVI.

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Author and article information

Journal

Journal ID (nlm-ta): J Neuroendovasc Ther

Journal ID (iso-abbrev): J Neuroendovasc Ther

Title: JNET Journal of Neuroendovascular Therapy

Publisher: The Japanese Society for Neuroendovascular Therapy

ISSN (Print): 1882-4072

ISSN (Electronic): 2186-2494

Publication date (Electronic): 1 September 2023

Publication date (Print): 2023

Volume: 17

Issue: 12

Pages: 286-292

Affiliations

[1 ]departmentDepartment of Neurosurgery , Tsuchiura Kyodo General Hospital , Tsuchiura, Ibaraki, Japan

[2 ]departmentDepartment of Endovascular Surgery , Tokyo Medical and Dental University , Tokyo, Japan

Author notes

Corresponding author: Shin Hirota. Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki 300-0028, Japan

Email: hiroshin_21@ 123456yahoo.co.jp

Article

Publisher ID: jnet.cr.2023-0041

DOI: 10.5797/jnet.cr.2023-0041

PMC ID: 10730297

PubMed ID: 38125961

SO-VID: 1952f0bb-10b1-40f9-b1d7-85c89ad1a2cd

License:

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License

Mechanical Thrombectomy and Parent Artery Occlusion for Acute Basilar Artery Occlusion Due to Vertebral Fracture and Artery Dissection: A Case Report

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Abstract

Objective

Case Presentation

Conclusion

Related collections

Fracture and Structural Integrity

Most cited references 20

Blunt cerebrovascular injuries: does treatment always matter?

Optimizing screening for blunt cerebrovascular injuries.

Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography.

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Journal

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