title: Delayed endovascular revascularization in a patient with progressive neurological deterioration from bilateral intracranial vertebral artery occlusions: case report.
abstract: BACKGROUND
  This article describes delayed endovascular revascularization in a patient with clinical and radiographic evidence of posterior circulation hemodynamic failure in the setting of intracranial occlusive lesions.
  
  
  METHODS
  A 48-year-old man presented with a 6-week history of progressive headache, nausea, and ataxia. Bilateral intracranial vertebral artery occlusions and a left posterior inferior cerebellar artery stroke were diagnosed, and the patient began warfarin therapy. Despite these measures, the patient developed dense lower cranial neuropathies, including severe dysarthria, decreased left-sided hearing acuity, and left facial droop. He presented at this point for endovascular evaluation. The patient underwent successful revascularization with intravascular Wingspan stents (Boston Scientific, Natick, Massachusetts) in a delayed fashion (approximately 6 weeks after his initial stroke presentation). His neurological syndrome stabilized and began to improve slowly.
  
  
  CONCLUSIONS
  Patients with arterial occlusion should be evaluated acutely for potential revascularization. In the posterior circulation, clinical progression may supplant physiological imaging in the assessment of hemodynamic collapse. A subpopulation of patients will present with progressive deficits distinct from extracranial manifestations of vertebrobasilar insufficiency; these patients should be considered for delayed revascularization.
authors.affiliation: Neurovascular Service, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. cogilvy@partners.org
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Ogilvy
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Khalessi
authors.forename: Erik F
authors.initials: EF
authors.lastname: Hauck
authors.forename: Larry R
authors.initials: LR
authors.lastname: Shannon
authors.forename: L Nelson
authors.initials: LN
authors.lastname: Hopkins
authors.forename: Elad I
authors.initials: EI
authors.lastname: Levy
authors.forename: Adnan H
authors.initials: AH
authors.lastname: Siddiqui
mesh_terms: D001157:Arterial Occlusive Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D002533:Cerebral Angiography / Q000379:methods; D002548:Cerebral Revascularization / Q000379:methods*; D018450:Disease Progression; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D014715:Vertebrobasilar Insufficiency / Q000150:complications / Q000175:diagnosis / Q000601:surgery*