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Vertebral artery stenting in a patient with reversed flow in the anterior spinal artery
  1. Jordan Dubow1,
  2. Howard Riina2,
  3. Athos Patsalides2
  1. 1Department of Neurology and Neurosciences, Weill Cornell Medical College, NewYork, USA
  2. 2Departments of Neurosurgery and Radiology, Weill Cornell Medical College, NewYork, USA
  1. Correspondence to Dr Jordan Dubow, Department of Neurology and Neurosciences, Weil Cornell Medical College, 525 East 68th Street, F610, NY 10065, New York, USA; jsd9001{at}nyp.org

Abstract

We present neuroimages for a patient in a locked-in state with reversed flow in the anterior spinal artery as a result of bilateral distal vertebral artery occlusion. Following vertebral artery stenting, there is markedly improved flow in the posterior circulation and significant neurological recovery.

  • All cerebrovascular disease/stroke
  • all imaging
  • artery
  • atherosclerosis
  • brainstem infarction
  • stent
  • stroke
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A patient was transferred to our hospital with brainstem stroke (figure 1A), waxing and waning symptoms of a locked-in state and distal bilateral vertebral artery occlusion. The patient initially presented to an outside hospital 3 weeks earlier with vertigo. Two days after admission to the outside hospital the patient developed upper and lower extremity weakness. The patient's exam subsequently fluctuated between a completely locked-in state and limited eye opening with minimal limb movement. The patient was than transferred to our institution for further management.

Figure 1

MRI shows restricted diffusion in the pons (A). Catheter angiogram of the right vertebral artery shows distal vertebral artery occlusion with retrograde flow from the anterior spinal artery (arrows) supplying the vertebrobasilar circulation (B). Selected left internal carotid artery angiogram shows slow, delayed, retrograde flow into the left posterior cerebral artery (arrowheads) and the top of the basilar artery (arrow) via pial collaterals from the middle cerebral artery to the posterior cerebral artery (C). Similar findings were seen with right internal carotid artery angiogram (not shown).

On catheter angiography, the intracranial vertebral artery segments and the proximal basilar artery were only supplied by retrograde flow through the anterior spinal artery (figure 1B). Right and left carotid angiograms did not show posterior communicating arteries. However, there was slow, delayed, retrograde flow into the left posterior cerebral artery and the top of the basilar artery via pial collaterals from the middle cerebral artery to the posterior cerebral artery (figure 1C). The patient underwent successful right vertebral artery stenting resulting in markedly improved flow through the posterior circulation (figure 2). Following the procedure the patient's neurological exam significantly improved. Upon discharge to a rehabilitation facility, the patient was awake, alert and following all commands. The patient was able to move all limbs against gravity with some resistance.

Figure 2

Post-angioplasty and stenting angiogram shows recanalization of the right vertebral artery with significantly improved flow through the posterior circulation with normalization of flow through the anterior spinal artery.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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