title: Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations-Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke.
abstract: Patients suffering from acute atherothrombotic occlusion of the proximal vertebral artery (VA) and concomitant basilar artery (BA) occlusion present a grim prognosis. We describe our experience in the endovascular recanalization of tandem vertebrobasilar occlusions using endovascular techniques. The BA was accessed through the normal VA (clean-road) or the occluded, thrombotic VA (dirty-road), and stentriever-based thrombectomy was performed using antegrade or reverse revascularization variants. Seven patients underwent successful stentriever-assisted mechanical thrombectomy of the BA and five sustained concomitant VA revascularization. Stroke onset to endovascular intervention initiation (time-to-treatment) ranged from 4.5-13hours (mean 8.6). In two of seven patients, the BA occlusion was approached with a 'clean-road' approach via the contralateral VA; in five of seven patients, a 'dirty-road' approach via the occluded VA was used. Mean time-to-recanalization was 66minutes (range 55-82). There were no perforations, iatrogenic vessel dissections, or other technical complications. Four patients presented mild-to-moderate disability (modified Rankin Scale [mRS] 0-3) at 3months, one remained with moderate-to-severe disability (mRS 4), and two patients died on days 9 and 23 after their strokes. Follow-up ranged from 6-45months (mean 24months). In selected patients with acute VA-BA occlusion, stentriever-based thrombectomy performed through either the patent or the occluded VA, may be feasible, effective, and safe. Clinical outcomes in these patients seem to equipoise the neurological outcome of patients with successful revascularization for isolated BA occlusion. This unique pair of occlusions confirms the role of VA ostium stenosis as a cause of vertebrobasilar stroke.
authors: Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Electronic address: jcohenns@yahoo.com.
authors: José E
authors: JE
authors: Cohen
authors: Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors: Ronen R
authors: RR
authors: Leker
authors: Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors: J Moshe
authors: JM
authors: Gomori
authors: Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors: Roni
authors: R
authors: Eichel
authors: Department of Neurosurgery, Schneider Hospital, Tel Aviv, Israel.
authors: Gustavo
authors: G
authors: Rajz
authors: Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors: Samuel
authors: S
authors: Moscovici
authors: Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors: Eyal
authors: E
authors: Itshayek
mesh_terms: D000368:Aged; D017130:Angioplasty; D001488:Basilar Artery / Q000601:surgery; D002548:Cerebral Revascularization / Q000379:methods; D004185:Disability Evaluation; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000209:etiology; D008297:Male; D008875:Middle Aged; D015607:Stents; D020521:Stroke / Q000209:etiology* / Q000401:mortality; D017131:Thrombectomy; D016896:Treatment Outcome; D014715:Vertebrobasilar Insufficiency / Q000150:complications* / Q000401:mortality / Q000601:surgery*
keywords: Basilar artery occlusion; Stroke; Tandem occlusion; Thrombectomy; Thrombolysis; Vertebral artery occlusion