J Cerebrovasc Endovasc Neurosurg.  2014 Sep;16(3):281-286. 10.7461/jcen.2014.16.3.281.

Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up

Affiliations
  • 1Department of Neurosurgery, Myongji St. Mary's Hospital, Seoul, Korea. nshs@catholic.ac.kr

Abstract

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.

Keyword

Vertebral artery hypoplasia; Free floating thrombi; Endovascular treatment; Vertebral artery origin stenosis

MeSH Terms

Angioplasty*
Arteries
Compensation and Redress
Constriction, Pathologic*
Embolism
Follow-Up Studies*
Hemodynamics
Humans
Ischemia
Risk Factors
Stroke
Vertebral Artery*

Figure

  • Fig. 1 (A,B) Diffusion weighted magnetic resonance imaging (MRI) of the brain shows focal high signal intensities in the right cerebellar hemisphere, occipital area, and splenium of the corpus callosum. (C) No significant steno-occlusive lesions are detected on intracranial MR angiography (MRA). (D) Gadolinium-enhanced cervical MRA demonstrates the prominent left vertebral artery and invisible long segment of the proximal right vertebral artery.

  • Fig. 2 (A) Pre-stenting angiogram of the right vertebral artery shows severe stenosis of the right vertebral artery origin (white arrowhead) and multiple filling defects distal to the stenosis (black arrowheads). (B) Angiogram obtained immediately after vertebral artery origin stent placement shows significant improvement in the stenosis (white arrow) and continued multiple filling defects in the right vertebral artery. (C) A two-week follow-up angiogram shows a patent vertebral artery orifice after placement of a stent and the previously noted multiple thrombi in the right vertebral artery had disappeared.


Reference

1. Amole AO, Akdol MS, Wood CE, Keyrouz SG, Erdem E. Endovascular management of symptomatic vertebral artery origin stenosis in the presence of an acute thrombus. J Neurointerv Surg. 2012; 7. 4(4):e11. PMID: 21990503.
Article
2. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991; 6. 337(8756):1521–1526. PMID: 1675378.
Article
3. Bhatti AF, Leon LR Jr, Labropoulos N, Rubinas TL, Rodriguez H, Kalman PG, et al. Free-floating thrombus of the carotid artery: literature review and case reports. J Vasc Surg. 2007; 1. 45(1):199–205. PMID: 17210411.
Article
4. Wang Y, Cai A, Liu L, Wang Y. Sonographic diagnosis of congenital variations of the extracranial vertebral artery and assessment of its circulation. J Ultrasound Med. 2009; 11. 28(11):1481–1486. PMID: 19854962.
Article
5. Caplan LR, Baker R. Extracranial occlusive vascular disease: does size matter? Stroke. 1980; Jan-Feb. 11(1):63–66. PMID: 7355432.
6. Chuang YM, Huang YC, Hu HH, Yang CY. Toward a further elucidation: role of vertebral artery hypoplasia in acute ischemic stroke. Eur Neurol. 2006; 55(4):193–197. PMID: 16772715.
Article
7. Chuang YM, Hwang YC, Lin CP, Liu CY. Toward a further elucidation: role of vertebral artery hypoplasia in migraine with aura. Eur Neurol. 2008; 59(3-4):148–151. PMID: 18057902.
Article
8. Furie B, Furie BC. Mechanisms of thrombus formation. N Engl J Med. 2008; 8. 359(9):938–949. PMID: 18753650.
Article
9. Giannopoulos S, Markoula S, Kosmidou M, Pelidou SH, Kyritsis AP. Lateral medullary ischaemic events in young adults with hpoplastic vertebral artery. J Neurol Neurosurg Psychiatry. 2007; 9. 78(9):987–989. PMID: 17702781.
10. Hagedorn I, Vögtle T, Nieswandt B. Arterial thrombus formation. Novel mechanisms and targets. Hamostaseologie. 2010; 8. 30(3):127–135. PMID: 20680230.
11. Igawa T, Nagamura Y, Ozeki Y, Itoh H, Unemi F. Stenosis enhances role of platelets in growth of regional thrombus and intimal wall thickening in rat carotid arteries. Circ Res. 1995; 8. 77(2):310–316. PMID: 7614718.
Article
12. Kalangos A, Baldovinos A, Vuille C, Montessuit M, Faidutti B. Floating thrombus in the ascending aorta: a rare cause of peripheral emboli. J Vasc Surg. 1997; 7. 26(1):150–154. PMID: 9240336.
Article
13. Katsanos AH, Kosmidou M, Giannopoulos S. Vertebral artery hypoplasia in posterior circulation cerebral ischemia. Clin Neurol Neurosurg. 2013; 7. 115(7):1194–1195. PMID: 22944469.
Article
14. Katsanos AH, Kosmidou M, Kyritsis AP, Giannopoulos S. Is vertebral artery hypoplasia a predisposing factor for posterior circulation cerebral ischemic events? A comprehensive Review. Eur Neurol. 2013; 70(1-2):78–83. PMID: 23816871.
Article
15. Kim SD, Hwang JK, Lee JH, Cho HJ, Sung GY, Moon IS, Kim JI. Free floating thrombus of the aorta: an unusual cause of peripheral embolization. J Korean Surg Soc. 2011; 3. 80(3):204–211.
Article
16. Park JH, Roh JK, Kwon HM. Ischemic stroke patterns and hemodynamic features in patients with small vertebrobasilar artery. J Neurol Sci. 2009; 12. 287(1-2):227–235. PMID: 19682709.
Article
17. Savage B, Almus-Jacobs F, Ruggeri ZM. Specific synergy of multiple substrate-receptor interactions in platelet thrombus formation under flow. Cell. 1998; 9. 94(5):657–666. PMID: 9741630.
Article
18. Vilimas A, Barkauskas E, Vilionskis A, Rudzinskaite J, Morkunaite R. Vertebral artery hypoplasia: importance for stroke development, the role of the posterior communicating artery, possibility for surgical and conservative treatment. Acta Med Litu. 2003; 10(2):110–114.
19. Watanabe M, Takahashi A, Hashizume Y, Motegi Y, Furuse K. The correlation between vertebral artery asymmetry and pontine infarction- an MR angiography study. Rinsho Shinkeigaku. 1992; 7. 32(7):708–712. Japanese. PMID: 1291160.
Full Text Links
  • JCEN
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr