Acute Placement of Telescoping Open Cell Stents and Thrombectomy for Progressive Symptomatic Vertebrobasilar Dissection: 2-Dimensional Operative Video

Abstract

Spontaneous vertebral artery dissections are a rare, but potentially devastating cause of ischemic stroke in young patients. Multiple predisposing factors have been identified including collagen abnormalities and arterial hypertension. [1][2][3] Treatment of dissections may vary based on location, presentation, and patient comorbidities. Traditionally, ischemic symptoms are treated more conservatively than their hemorrhagic counterparts. 4 There are reports in the literature documenting the use of stents for reconstruction of occlusions secondary to vertebral artery dissections. [5][6][7][8][9][10][11][12][13][14] We present the case of a 27-year-old woman who presented after a syncopal event with headaches, ptosis, diplopia, and ataxia. Computed tomography angiogram demonstrated left vertebral artery dissection, near occlusion of the basilar artery, and a hypoplastic right vertebral artery. Despite best medical management, the patient developed worsening weakness and ischemic symptoms, with an MRI revealing new right pontine infarcts. Given her young age and continued progression of symptoms and brainstem strokes, the decision was made to proceed with mechanical thrombectomy and subsequent placement of telescoping open cell stents to treat the vertebral artery dissection. Stent choices include the Neuroform Atlas or Enterprise stents. Paying attention to the landing zones for telescoping stents is critical for optimal placement. Postoperatively, the patient was maintained on her dual antiplatelet therapy regimen and was neurologically intact at the 3-month follow-up. We review the case presentation, angiographic findings, and postoperative course with imaging. The patient provided informed consent for the procedure and for inclusion in this submission. The use of an intracranial stent for repair of an intracranial dissection is an off-label use of the device; however, in this situation, it proved to be clinically important in achieving a good clinical outcome.

Commentary: Acute Placement of Telescoping Open Cell Stents and Thrombectomy for Progressive Symptomatic Vertebrobasilar Dissection: 2-Dimensional Operative Video

“…The authors present a case of spontaneous intracranial vertebral artery dissection in a young patient, outlining the treatment paradigm and the decision-making involved to ultimately achieve a great outcome. 1…”

“…T he authors present a case of spontaneous intracranial vertebral artery dissection in a young patient, outlining the treatment paradigm and the decision-making involved to ultimately achieve a great outcome. 1 Although intracranial vertebral artery dissections can have devastating clinical consequences as a result of ischemic 2 or hemorrhagic 2,3 sequelae, this disease is so rare to have standardized guidelines on management. The authors mention using the "best medical therapy," which challenges an important knowledge gap in the current literature, as there is no consensus as to the best medical therapy for these lesions and is largely individualized based on the managing physician preference.…”