title: Indirect reperfusion in the setting of symptomatic carotid occlusion by treatment of bilateral vertebral artery origin stenoses.
abstract: BACKGROUND
  Patients with total carotid occlusions can develop ischemic stroke as a result to hemodynamic impairment. Flow augmentation can be provided through a variety of surgical and endovascular techniques. We describe a patient treated with vertebral artery stent placement to augment indirect flow to the territory of an occluded carotid artery.
  
  
  METHODS
  A 52-year-old man presented with ST elevation myocardial infarction and ischemic stroke manifesting with right-sided hemiparesis and aphasia. A computed tomography (CT) angiogram confirmed the presence of a left internal carotid artery total occlusion with prolongation of the mean transit time and reduced estimated cerebral blood flow on CT perfusion maps. The patient was taken for angiography and found to have bilateral vertebral artery ostial stenosis and a posterior communicating artery supplying the left hemisphere.
  
  
  RESULTS
  The patient underwent successful stenting and angioplasty of both lesions with stabilization of neurologic symptoms. A follow-up CT perfusion study showed marked improvement in the estimated cerebral blood flow, and reduction of the mean transit time.
  
  
  CONCLUSIONS
  Stenting and angioplasty of a stenosis of an artery providing indirect blood flow to the territory of an occluded ipsilateral vessel can stabilize neurologic decline and improve CT perfusion parameters.
authors.affiliation: Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Mark
authors.initials: M
authors.lastname: Bain
authors.affiliation: Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Muhammad Shazam
authors.initials: MS
authors.lastname: Hussain
authors.affiliation: Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Vivek
authors.initials: V
authors.lastname: Gonugunta
authors.affiliation: Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Shaye
authors.initials: S
authors.lastname: Moskowitz
authors.affiliation: Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Ferdinand K
authors.initials: FK
authors.lastname: Hui
authors.affiliation: Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: guptar@ccf.org.
authors.forename: Rishi
authors.initials: R
authors.lastname: Gupta
mesh_terms: D015901:Angiography, Digital Subtraction; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects; D016893:Carotid Stenosis / Q000150:complications / Q000628:therapy*; D002533:Cerebral Angiography; D002560:Cerebrovascular Circulation / Q000502:physiology; D005263:Femoral Artery / Q000601:surgery; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009288:Naproxen / Q000009:adverse effects; D009460:Neurologic Examination; D010291:Paresis / Q000209:etiology; D015424:Reperfusion; D015607:Stents; D014057:Tomography, X-Ray Computed; D014715:Vertebrobasilar Insufficiency / Q000150:complications / Q000628:therapy*
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D009288:Naproxen