- Department of Neurosurgery, University of Tsukuba, Japan.
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan.
Eiichi Ishikawa, Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan.
DOI:10.25259/SNI_384_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Akinari Yamano1, Yasunobu Nakai2, Kazuki Akutagawa1, Haruki Igarashi2, Kazuaki Tsukada1, Toshitsugu Terakado1, Kazuya Uemura2, Eiichi Ishikawa1. Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome. 06-Sep-2021;12:445
How to cite this URL: Akinari Yamano1, Yasunobu Nakai2, Kazuki Akutagawa1, Haruki Igarashi2, Kazuaki Tsukada1, Toshitsugu Terakado1, Kazuya Uemura2, Eiichi Ishikawa1. Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome. 06-Sep-2021;12:445. Available from: https://surgicalneurologyint.com/surgicalint-articles/11096/
Background: Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin.
Case Description: The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy.
Conclusion: Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.
Keywords: Endovascular treatment, Ischemic stroke, Stroke, Vertebral artery stump syndrome
Vertebral artery stump syndrome (VASS) presents with recurrent posterior circulation (PC) stroke after ipsilateral vertebral artery (VA) occlusion at its origin.[
A 46-year-old man arrived at our emergency room with sudden, disturbed consciousness, left homonymous hemianopsia, left hemiplegia, and left hypoesthesia. The National Institutes of Health Stroke Scale (NIHSS) score was 10. Magnetic resonance (MR) diffusion-weighted imaging revealed slightly high-intensity signals in the right occipital lobe, right thalamus, and right hippocampus [
Angiography of the left subclavian artery. The left VA was occluded from its origin (a). Anterior-posterior view (b) and lateral view (c) of angiography of the left subclavian artery. The left deep cervical artery was anastomosed to the left VA and its antegrade flow in the VA was stagnant. VA: Vertebral artery.
In 2008, Nguyen et al. reported two cases of recurrent PC stroke due to VA origin occlusion, calling it “VASS” because of the clinical similarities to carotid stump syndrome.[
Intravenous rt-PA is known as an effective treatment for acute ischemic stroke[
Endovascular treatment is reported to permanently prevent recurrent stroke, as seen when Nguyen et al. reported two cases of VASS treated with coil embolization to exclude the embolic source at the VA.[
There are several reports of endovascular treatment for BAO due to VASS.[
In our case, the stagnant flow at the VA continued to produce new thrombi despite IV rt-PA use. Because the volume from the VA origin to the anastomosis with the collaterals was relatively large, the stagnant flow had enough space to produce a large thrombus, which had the potential to occlude the BA. The possibility of recurrent stroke, including fatal BA occlusion, must be considered, especially in the acute phase, if antithrombotic therapy is withheld. Even though VASS is not a rare cause of PC stroke, only a few cases have been reported. The concept of VASS must be spread for the sake of accurate diagnosis and to accumulate case numbers sufficient for evaluating the efficacy and safety of early use of antithrombotic and/or radical endovascular treatment.
In patients with PC ischemic stroke featuring VA occlusion, VASS, as a dangerous syndrome involving the risk of fatal recurrent stroke, must be considered as its embolic source. In the present case, fatal BA occlusion developed within 24 h of rt-PA use but administration of rt-PA restricted the early introduction of antithrombotic therapy. Vigilance against such fatal, recurrent strokes must therefore be maintained, particularly when antithrombotic therapy is restricted.
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