Stenting for Severe Vertebral Artery Orifice Stenosis in A Case of Three Cerebral Artery Occlusion

Abstract

The vertebrobasilar system (VBS) is responsible for causing 25% of ischemic strokes (1, 2). Approximately one-fifth of the posterior system strokes are caused due to the stenosis developing at the exit site of the extracranial vertebral artery (VA) from the subclavian artery (3). VA orifice stenoses are among the correctable causes of posterior system strokes that can be treated using developed imaging and treatment modalities. Case ReportA 51-year-old male patient visited our clinic with a complaint of speech impairment and weakness on the left side. He had undergone a surgery for aortic coarctation 13 years ago and for transient ischemic episodes progressing along with speech impairment 5 years ago. Regarding his habits, he had a history of smoking a pack of cigarettes a day for 30 years. Neurological examination showed that he was conscious and cooperative and his orientation was complete. His speech was dysarthric. Left hemiparesis (4/5, 4/5) was detected on the motor examination. Magnetic resonance imaging revealed right hemisphere caudate nucleus and frontoparietal fragmented acute infarct (Figure 1). Acetylsalicylic acid (ASA) 100 mg and enoxaparin 0.6 mL 2 × 1 were started subcutaneously as treatment. Vasculitis examinations did not show any characteristics. The ejection fraction (EF) was 60%, and the left ventricular systolic functions were normal in transesophageal echocardiography (TEE). The right VA had a dolichoectasia appearance in color Doppler ultrasonography (CDU). The total VA current was 267 mL/min. Cranial and cervical magnetic resonance angiography (MRA) showed that cerebral blood flow was provided only by the narrow right VA (Figure 2). There was a slight deterioration in the left hemiparesis (2/5, 4/5) during the hospitalization. During cerebral digital subtraction angiography (DSA) performed by the neuroradiology team, a guiding catheter was inserted in the right VA because of the advanced occlusion in both ICAs (internal carotid arteries) and in the left VA outflow tract and 80% stenosis in the right VA orifice. The stenosis level was passed using a 0.14 guidewire through the guiding catheter, and a 6 × 12 mm balloon expandable stent was brought to the place of stenosis through the guidewire and opened. The procedure was terminated after the stent lumen was monitored open in the control images (Figure 3). Dysarthria and left hemiparesis (3/5,-5/5) were detected on the final neurological examination of the patient. Prasugrel 10 mg/ day and ASA 300 mg/day were started as medical treatment due to clopidogrel resistance (92 U, sensitivity 24 U), and then the patient was discharged. At the first-and fifth-month Stenting for Severe Vertebral Artery Orifice Stenosis in A Case of Three Cerebral Artery Occlusion A 51-year-old male presented with dysarthria and weakness on his left side. In his history, he had an operation due to aortic coarctation 13 years ago, and 5 years ago, he had a transient ischemic attack along with difficulty in speaking. During his neurological examination, he was consci...

Intravenous Thrombolytic Therapy for Acute Ischemic Stroke: Experiences of a Tertiary Hospital in Turkey

“…Although the official numbers in Turkey are not known, the IV tPA application is known not to be widely used and studies aiming at creating awareness in this regard should be done in Turkey 6,7 . On the other hand, the number of studies showing that tPA therapy has been recently used more widely in many clinics in Turkey and compiling the clinics' experiences on thrombolytic treatment has been increasing gradually [8][9][10][11][12] . In our clinic, tPA treatment has been applied since 2015 and there is an increase in the number of patients receiving tPA therapy every year.…”