Posterior Inferior Cerebellar Artery Stroke Due to a Severe Right Vertebral Artery Stenosis With a Left Cervical Internal Carotid Artery Dissection: What's Next?

Guidelines for the treatment and management of ischemic strokes triggered by stenosis versus dissection are well established. However, the presence of both entities in the same patient, although rare, poses challenges for short- and long-term treatment. Here, we describe the case of a 55-year-old man who presented to the emergency department with a 72-hour history of headache, dizziness, unbalanced gait, nausea, and two episodes of vomiting. Stroke was initially suspected, but the computerized tomography (CT) scan showed no hemorrhage. His magnetic resonance imaging (MRI) showed right inferior cerebellar acute ischemia in the territory of the right posterior inferior cerebellar artery (PICA), with smaller foci of early acute infarcts in the bilateral inferior cerebellum. Furthermore, magnetic resonance angiography (MRA) and CT angiography revealed right vertebral artery stenosis and left cervical internal carotid artery dissection (ICAD). This clinical report describes a rare case of stroke secondary to vertebral artery stenosis with concomitant carotid artery dissection. The treatment course and evolution are presented.

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

SUMMARY: The aim of this study was to compare the clinical value of vertebral artery ultrasound (VAU), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) on vertebral artery stenosis in patients with posterior circulation ischemia. Seventy-three patients with posterior circulation ischemia underwent vertebral artery ultrasound and magnetic resonance angiography as well as digital subtraction angiography, and the diagnosis of vertebral artery stenosis (VAS) and the degree of stenosis (normal, mild stenosis, moderate stenosis, severe stenosis, and occlusion) were recorded and compared between digital subtraction angiogram and vertebral artery ultrasound and magnetic resonance angiography. The vertebral artery stenosis rates on digital subtraction angiography and vertebral artery ultrasound were 87.30 % (55/63) and 49.20 % (31/63), respectively, and the difference was statistically significant. The rates of vertebral artery stenosis on digital subtraction angiography and, magnetic resonance angiography was 90.38 % (47/52) and 88.46 % (46/ 52), respectively, and the differences was not statistically significant. The sensitivity, accuracy, negative predictive value, and positive predictive value of vertebral artery ultrasound in diagnosing vertebral artery stenosis were 51.35 %, 54.76 %, 18.18 %, and 95.00 %, respectively, lower than those of magnetic resonance angiography, which were 91.89 %, 90.48 %, 57.14 %, and 97.14 %, respectively. Of the noninvasive imaging techniques, vertebral artery ultrasound does not accurately characterize vertebral artery stenosis and its degree of stenosis. Magnetic resonance angiography effectively screens for vertebral artery stenosis and its degree of stenosis, and can be used as a reliable tool for vertebral artery stenosis in posterior circulation cerebral infarction, and can be used in conjunction with digital subtraction angiogram in order to improve diagnostic convenience and accuracy.

El objetivo de este estudio fue comparar el valor clínico de la ecografía de la arteria vertebral (VAU), la angiografía por resonancia magnética (ARM) y la angiografía por sustracción digital (DSA) en la estenosis de la arteria vertebral en pacientes con isquemia de la circulación posterior. A 73 pacientes con isquemia de la circulación posterior se les realizó una ecografía de la arteria vertebral y una angiografía por resonancia magnética, así como una angiografía por sustracción digital, y se les diagnosticó estenosis de la arteria vertebral (EVA) y el grado de estenosis (normal, estenosis leve, estenosis moderada, estenosis grave, y oclusión) se registraron y compararon la angiografía por sustracción digital y la ecografía de la arteria vertebral y la angiografía por resonancia magnética. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la ecografía de la arteria vertebral fueron del 87,30 % (55/63) y del 49,20 % (31/63), respectivamente, y la diferencia fue estadísticamente significativa. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la angiografía por resonancia magnética fueron del 90,38 % (47/52) y del 88,46 % (46/52), respectivamente, y las diferencias no fueron estadísticamente significativas. La sensibilidad, precisión, valor predictivo negativo y valor predictivo positivo de la ecografía de la arteria vertebral en el diagnóstico de estenosis de la arteria vertebral fueron 51,35 %, 54,76 %, 18,18 % y 95,00 %, respectivamente, inferiores a los de la angiografía por resonancia magnética, que fueron 91,89 %, 90,48 %, 57,14 % y 97,14 %, respectivamente. De las técnicas de imagen no invasivas, la ecografía de la arteria vertebral no caracteriza con precisión la estenosis de la arteria vertebral y su grado de estenosis. La angiografía por resonancia magnética detecta eficazmente la estenosis de la arteria vertebral y su grado de estenosis, y puede usarse como una herramienta confiable para la estenosis de la arteria vertebral en el infarto cerebral de circulación posterior, y puede ser utilizada junto con la angiografía por sustracción digital para mejorar el diagnóstico y la exactitud.

Endovascular Approach in Treating Vertebrobasilar Insufficiency: A Systematic Review.

Vertebrobasilar insufficiency (VBI) is a significant medical condition that results from a lack of adequate blood flow to the posterior circulation of the brain. The first-line treatment involves the use of antiplatelet therapy, but in cases where patients are not responsive to drug therapy, surgical management is the next viable option. In the past, open endarterectomy was the preferred surgical approach for treating critical VBI patients. However, due to its high mortality rates and severe peri-procedural complications, its usage has decreased. Instead, the endovascular approach has emerged as an alternative surgical option for resolving VBI. This review explores the current literature to assess the effectiveness of endovascular interventions in treating VBI patients. It also highlights potential complications and adverse effects associated with these treatments while identifying gaps in the current research that warrant further investigation. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to extensively search relevant literature on endovascular approaches for treating VBI patients on PubMed, BioMed Central, and ClinicalTrials.gov. The findings suggest that endovascular treatments have demonstrated significant technical success in treating VBI, with low mortality rates and minor adverse effects, such as intracranial hemorrhage and restenosis. The overall incidence of these complications is relatively low. Combining medical therapies with endovascular interventions has improved outcomes and reduced restenosis rates. However, there are methodological limitations and inconsistencies in the current literature that necessitate further investigation. Future research should focus on larger, randomized clinical trials and direct comparisons with other treatment options to obtain more conclusive evidence.

Endovascular Treatment May Be Effective in Preventing Recurrence of Ischemic Stroke in Vertebral Artery Stump Syndrome: A Case Series.

Vertebral artery stump syndrome (VASS) is a rare condition that can cause posterior circulation ischemic stroke due to occlusion of the ipsilateral vertebral artery (VA) orifice, resulting in blood flow stagnation and embolus formation. Although there is no established treatment for this condition, we observed 3 cases of VASS out of 326 acute ischemic stroke cases at a single institution from April 2021 to October 2022. Despite the best possible antithrombotic treatment, all 3 patients had recurrent ischemic strokes. One patient underwent drug-eluting stenting of the VA orifice to relieve occlusive flow. The other 2 patients received coil embolization, which resulted in the disappearance of their culprit collateral flow. None of the patients had recurrent ischemic strokes after endovascular intervention. Based on our observations, stenting and coil embolization are effective methods for preventing future recurrences of VASS.

Clinical efficacy of rapamycin-eluting vertebral artery stents in the treatment of severe ostial vertebral artery stenosis / 介入放射学杂志

Objective To investigate the clinical effect of rapamycin-eluting vertebral artery stent in the treatment of severe ostial vertebral artery stenosis(OV AS),and to analyze the incidence of postoperative in-stent restenosis(ISR).Methods A total of 96 patients with severe OVAS,who received stenting angioplasty at authors'hospital between November 2020 and May 2022,were retrospectively collected.The patients were divided into the observation group(n=48)and the control group(n=48).For the patients of the observation group implantation of rapamycin-eluting vertebral artery stent was carried out,while for the patients of the control group implantation of peripheral balloon dilatation bare metal stent(BMS)was performed.The perioperative basic data,the incidence of complications during follow-up period,and the postoperative incidence of ISR were compared between the two groups.Results Successful stent implantation was achieved in all patients of both groups.During perioperative period no complications such as transient ischemia attack(TIA),dropping-off or fracture of the stent,vertebral artery or stent-related stroke occurred.No statistically significant differences in the length and the diameter of the implanted stents,in the preoperative vertebral artery stenosis ratio,and in the postoperative residual stenosis ratio existed between the two groups(all P＞0.05).In both groups,the postoperative residual stenosis ratio was＜20％.The patients were followed up for a mean period of(12.33±5.82)months(range of 6-18 months),the incidence of postoperative vertebral artery or stent-related stroke in the observation group and the control group was 0％and 4.17％respectively,the difference between the two groups was not statistically significant(P＞0.05).The improvement of clinical symptoms such as dizziness,vertigo,etc.was observed in 47 patients of the observation group and in 45 patients of the control group,and no recurrent posterior circulation TIA or stent-related thrombotic event occurred.The incidence of postoperative restenosis in the observation group was 10.42％,which was significantly lower than 29.17％in the control group(P＜0.05).Conclusion Rapamycin-eluting vertebral artery stent can safely and effectively treat severe OVAS and reduce the incidence of postoperative ISR.(J Intervent Radiol,2024,33:275-279)

A rare association of subclavian steal syndrome with bilateral carotid artery stenosis: a case report.

Bilateral carotid artery stenosis in the context of subclavian steal syndrome is an extremely rare finding. We report the case of a 75-year-old woman who presented with a transient ischemic attack. Bilateral internal carotid stenosis associated with left subclavian steal syndrome was diagnosed. Left internal carotid endarterectomy was performed under locoregional anesthesia. Inflation of a blood pressure cuff reversed the neurologic symptoms that appeared after internal carotid clamping. This rarely reported case remains a challenge to diagnose and treat because of its complex mechanisms and multiple risk factors. Our case highlights the importance of the surgical strategy adopted and the need for a good initial assessment.

Cervical dumbbell-type tumor spontaneously shrinking following an ischemic stroke.

Background: Asymptomatic cervical dumbbell-type tumors can be incidentally diagnosed. Notably, the chronological changes in the size of these tumors have not been satisfactorily described. Case Description: A 57-year-old man was clinically followed for an asymptomatic cervical dumbbell-type tumor that had the appearance of a schwannoma on magnetic resonance (MR) images obtained over a 7-year period. Notably, the tumor compressed both the spinal cord and the right vertebral artery. At the end of the 7-year period, the patient sustained a cerebral infarction due to atherosclerosis of the right vertebral artery; the angiogram revealed both atherosclerosis and the tumor compressing the right vertebral artery. After the stroke/ischemic event, the tumor progressively shrunk on MR images obtained for the following 4 years, and the spinal cord compression was similarly relieved. Conclusion: Here, we report on a 57-year-old man with cervical MR images revealing that a cervical dumbbell schwannoma was progressively compressing both the spinal cord and the right vertebral artery. However, following a cerebral infarction, the tumor underwent spontaneous shrinkage over the next 4 years, thus relieving the compression.

Microsurgical revascularization of a symptomatic proximal vertebral artery: pilot experiences from a single center.

Background: Vertebral artery stenosis and occlusion (VASO) is a high-risk factor for posterior circulation stroke. Post-stent restenosis and drug tolerance have facilitated the exploration of microsurgical vascular reconstruction. This study aims to evaluate the safety and efficacy of microsurgical reconstruction of the proximal VA. Methods: Twenty-nine patients (25 men, aged 63.2 years) who had symptoms of posterior circulation ischemia underwent microsurgical revascularization for proximal VASO were retrospectively included in this study. Procedural complications and clinical and angiographic outcomes were reviewed. Results: Twelve, three, and five patients underwent VA endarterectomy, artery transposition, or both, respectively; seven patients underwent vertebral endarterectomy plus stent implantation; and two patients failed surgery because of the difficult exposure of the VA and the occurrence of vascular dissection. The perioperative period-related complications included seven cases of Horner's syndrome, five cases of hoarseness, and one case of chylothorax. No cases of perioperative stroke or death were reported. The mean follow-up period was 28.4 (8-62 months). Most patients improved clinically; however, the vertebrobasilar ischemia symptoms did not decrease significantly in two patients during the follow-up. Moreover, follow-up imaging was performed in all the patients, and no signs of anastomotic stenosis were reported. Conclusion: Microsurgical reconstruction is an alternative option that can effectively treat refractory proximal VASO disease and in-stent stenosis, with a high rate of postoperative vascular recirculation. Prospective cohort studies with larger sample sizes must be conducted to validate the above conclusions.

High-Flow Saphenous Vein Graft Bypass from Common Carotid Artery to Vertebral Artery (V2) for the Treatment of Vertebrobasilar Insufficiency Due to Bilateral Vertebral Artery Origin Stenosis.

Vertebrobasilar insufficiency can lead to devastating brainstem and posterior cerebral infarction without timely treatment.1 A 56-year-old man with a history of hypertension, hyperlipidemia, and diabetes mellitus presented to the clinic with right hemiparesis due to previous left cerebral hemispheric stroke. He also harbored a giant asymptomatic parieto-occipital meningioma incidentally diagnosed 2 years ago. Neuroimaging showed old left cerebral infarcts and a tumor that had remained stable in size. Cerebral angiography identified bilateral vertebral artery stenosis near their origin from the subclavian arteries with severe vertebrobasilar insufficiency. There was some collateral flow to the posterior cortex via the internal maxillary and occipital artery branch anastomoses. Despite recommendation, the patient decided to not undergo tumor resection, but opted for a high-flow bypass to the posterior circulation to prevent stroke. We used a saphenous vein graft to perform a high-flow extracranial-to-extracranial bypass revascularization of the ischemic vertebrobasilar circulation (Video 1). The patient tolerated the procedure well and was discharged without new deficits 4-days postoperatively. Most recent follow-up examination at 3 years after surgery revealed a patent bypass graft with no new adverse cerebrovascular events. The tumor remains asymptomatic without change in imaging characteristics. Cerebral bypasses remain useful tools in carefully selected patients for the treatment of complex aneurysms, complex tumors, and ischemic cerebrovascular diseases.2-7 We demonstrate an extracranial-to-extracranial high-flow bypass to revascularize the posterior cerebral circulation using a saphenous vein graft in a patient with vertebrobasilar insufficiency.

[Clinical Effect of Surgical Reconstruction of Extracranial Vertebral Artery].

Objective To evaluate the effect of surgical reconstruction of extracranial vertebral artery and to summarize the experience. Methods The clinical data of 15 patients undergoing surgical reconstruction of extracranial vertebral artery from September 2018 to June 2022 were collected.The operation methods,operation duration,intraoperative blood loss,operation complications,and relief of symptoms were retrospectively analyzed. Results Eleven patients underwent vertebral artery (V1 segment) to common carotid artery transposition,two patients underwent endarterectomy of V1 segment,two patients underwent V3 segment to external carotid artery bypass or transposition.The operation duration,intraoperative blood loss,and blocking time of common carotid artery varied within 120-340 min,50-300 ml,and 12-25 min,with the medians of 240 min,100 ml,and 16 min,respectively.There was no cardiac accident,cerebral hyperperfusion syndrome,cerebral hemorrhage or lymphatic leakage during the perioperative period.One patient suffered from cerebral infarction and three patients suffered from incomplete Horner's syndrome after the operation.During the follow-up (4-45 months,median of 26 months),there was no anastomotic stenosis,new cerebral infarction or cerebral ischemia. Conclusion Surgical reconstruction of extracranial vertebral artery is safe and effective,and individualized reconstruction strategy should be adopted according to different conditions.

Traumatic Vertebral Artery Stenosis Inflicted by Stray Arrow.

A 17-year-old female presented to the emergency room with an arrow sticking out the right aspect of her neck. Her vital signs were stable with systolic blood pressure of 117 mmHg, without either tachycardia, dyspnea, or signs of active bleeding. She was fully conscious with intact sensory and motor function on all extremities. Computed Tomography (CT) showed that the tip of the arrowhead lodged at the transverse foramen of the third cervical vertebra. Digital subtraction angiography revealed that the arrowhead lies posterior to the right vertebral artery, narrowly missing it by about two millimeters. Emergency surgery was arranged in hybrid operating suite. An occlusion balloon catheter was introduced to right vertebral artery but not inflated prior to extracting the arrowhead. After extraction, oozing from the wound was noted. We then inflated the balloon while the neurosurgeon performed hemostasis with gauze compression and electrocoagulation probe. The right vertebral angiography after releasing of the balloon showed focal narrowing of the artery without contrast extravasation. The patient was discharged on the fifth hospital day, and no anticoagulant was prescribed due to lack of neurological deficit. Pre-surgical planning and partnership with the neurosurgeon lead to the optimal outcome for this case.

The diagnosis and treatment of central retinal artery occlusion with severe cardio-cerebrovascular disease: a case report.

Background: Central retinal artery occlusion (CRAO) is an acute eye disease that seriously damages vision. Patients with CRAO often have a combination of various cardio-cerebrovascular diseases (CCVDs), and CRAO patients often ignore their cardio-cerebrovascular disorders because of their ocular symptoms. In addition, there are few reports about CRAO patients with CCVDs received effective interventions implemented. We report the diagnosis and treatment of a Chinese CRAO patient with CCVD who received timely multidisciplinary interventional therapy to provide ideas for clinical ophthalmologists in the diagnosis and treatment of similar diseases. Case Description: A 76-year-old male patient, who had previously been diagnosed with hypertension, was admitted to hospital due to a sudden decrease in vision in his right eye for >2 days with a severe headache. After fundus photography, he was diagnosed with CRAO in the right eye. His cerebral angiography revealed multiple stenoses at arteries of his neck and brain included the right ophthalmic artery. Neurosurgery was attempted to perform a thrombolysis of the right ophthalmic artery while performing the angiography, but failed to find the opening of the right ophthalmic artery. However, through electrocardiogram (ECG) monitoring during the operation, we found that the patient had frequent ventricular premature beats, so the Department of Cardiology performed coronary arteriography for him which revealed severe stenosis of the left anterior descending (LAD) artery. The cardiologists performed a percutaneous coronary intervention (PCI) at the same time as the coronary angiography. Some 2 months later, the patient was admitted to the Neurosurgery Department to implant stent at the left vertebral artery. After stent implantation, his headache symptom improved significantly and his right eye vision improved. Conclusions: Through timely cerebral angiography and ophthalmic examinations, the patient was diagnosed with CRAO combined with CCVD, and after received multidisciplinary interventional therapy, the patient's right eye vision and headache symptom improved and more severe cardio-cerebrovascular adverse events were avoided. In treating CRAO patients, in addition to aggressive eye treatment, the systemic cardio-cerebrovascular situation of each patient should also be assessed, a timely diagnosis made, and effective interventions implemented to reduce morbidity- and mortality-related cardio-cerebrovascular events.

Percutaneous transluminal angioplasty and stenting of post-irradiation stenosis of the vertebral artery.

BACKGROUND: The outcomes of percutaneous transluminal angioplasty and stenting (PTAS) in patients with medically refractory post-irradiation stenosis of the vertebral artery (PISVA) have not been clarified. AIM: This retrospective study evaluated the safety and outcomes of PTAS in patients with severe PISVA compared with their radiation-naïve counterparts (non-RT group). METHODS: Patients with medically refractory severe symptomatic vertebral artery stenosis and undergoing PTAS between 2000 and 2021 were classified as the PISVA group or the non-RT group. The periprocedural neurological complications, periprocedural brain magnetic resonance imaging, the extent of symptom relief, and long-term stent patency were compared. RESULTS: As compared with the non-RT group (22 cases, 24 lesions), the PISVA group (10 cases, 10 lesions) was younger (62.0 ± 8.6 vs 72.4 ± 9.7 years, P = 0.006) and less frequently had hypertension (40.0% vs 86.4%, P = 0.013) and diabetes mellitus (10.0% vs 54.6%, P = 0.024). Periprocedural embolic infarction was not significantly different between the non-RT group and the PISVA group (37.5% vs 35.7%, P = 1.000). At a mean follow-up of 72.1 ± 58.7 (3-244) months, there was no significant between-group differences in the symptom recurrence rate (0.00% vs 4.55%, P = 1.000) and in-stent restenosis rate (10.0% vs 12.5%, P = 1.000). CONCLUSION: PTAS of severe medically refractory PISVA is effective in the management of vertebrobasilar ischemic symptoms in head and neck cancer patients. Technical safety and outcome of the procedure were like those features in radiation-naïve patients.

Vertebral Artery Interventions: A Comprehensive Updated Review.

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis are promising options widely used in clinical practice with good technical results; however, the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. This review aims to provide a focused update on the percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach, and advances in medical therapies.

Carotid endarterectomy combined with vertebral artery transposition treating vertebral artery V1 segment stenosis combined with ipsilateral carotid artery stenosis / 中国胸心血管外科临床杂志

@#Objective    To explore the treatment outcome of carotid endarterectomy combined with vertebral artery transposition in patients with severe stenosis to occlusion of the vertebral artery V1 segment and the ipsilateral carotid artery. Methods    From June 2017 to September 2020, patients with severe stenosis to occlusion of the vertebral artery V1 segment and the ipsilateral carotid artery treated with carotid endarterectomy combined with vertebral artery transposition in Fuwai Hospital were retrospectively analyzed. Results    Finally 12 patients were enrolled, including 10 males and 2 females with an average age of 67.8±6.0 years. Twelve patients were successfully operated and the follow-up time was 1-3 years. The stenosis degree of the V1 segment of the vertebral artery decreased from 83.5%±11.8% to 24.9%±14.3% (P<0.001). The stenosis degree of carotid artery decreased from 85.6%±11.0% to 0% (P<0.001). Postoperative follow-up showed that the symptoms of symptomatic patients before surgery improved. The 1-year and 3-year patency rates were 100.0%, and there were no peripheral nerve injury complications, perioperative deaths or strokes. Conclusion    Carotid endarterectomy combined with vertebral artery transposition can treat ipsilateral carotid artery  stenosis and vertebral artery stenosis at the same time, improve blood supply to the brain, improve patients' symptoms and has high promotion value.

Clinical Effect of Surgical Reconstruction of Extracranial Vertebral Artery / 中国医学科学院学报

Objective To evaluate the effect of surgical reconstruction of extracranial vertebral artery and to summarize the experience. Methods The clinical data of 15 patients undergoing surgical reconstruction of extracranial vertebral artery from September 2018 to June 2022 were collected.The operation methods,operation duration,intraoperative blood loss,operation complications,and relief of symptoms were retrospectively analyzed. Results Eleven patients underwent vertebral artery (V1 segment) to common carotid artery transposition,two patients underwent endarterectomy of V1 segment,two patients underwent V3 segment to external carotid artery bypass or transposition.The operation duration,intraoperative blood loss,and blocking time of common carotid artery varied within 120-340 min,50-300 ml,and 12-25 min,with the medians of 240 min,100 ml,and 16 min,respectively.There was no cardiac accident,cerebral hyperperfusion syndrome,cerebral hemorrhage or lymphatic leakage during the perioperative period.One patient suffered from cerebral infarction and three patients suffered from incomplete Horner's syndrome after the operation.During the follow-up (4-45 months,median of 26 months),there was no anastomotic stenosis,new cerebral infarction or cerebral ischemia. Conclusion Surgical reconstruction of extracranial vertebral artery is safe and effective,and individualized reconstruction strategy should be adopted according to different conditions.

Severe Bilateral Vertebral Arterial Disease Masquerading as Vertigo.

Vertebral artery stenosis (VAS), manifesting as vertebrobasilar insufficiency (VBI), results from the narrowing of the vertebral artery's lumen because of diverse vascular pathological processes, leading to various clinical presentations. We present the case of a 71-year-old male who experienced vertigo for almost two years and was ultimately diagnosed with severe bilateral VAS. Despite initial management for vertigo, the patient's symptoms persisted, prompting a referral to a cardiologist. Several assessments were performed, including an MRI of the brain, which ruled out acute intracerebral hemorrhage or infarction. After some visits to the cardiologist's office, the patient was referred to a neurologist who conducted a magnetic resonance angiography (MRA) of the neck, which showed an occlusion of the left vertebral artery at the origin and a patent right vertebral artery. Because of worsening symptoms of vertigo and the results of the MRA, the patient underwent invasive angiography that confirmed the occlusion of the left vertebral artery and also revealed severe stenosis of the right vertebral artery. This case report discusses an unusual presentation of VAS with vertigo as the primary symptom, emphasizing the importance of recognizing seemingly minor symptoms as manifestations of the underlying vascular pathology that requires careful evaluation. Furthermore, this case emphasizes the limitation of relying solely on noninvasive imaging for diagnosis as, in this instance, noninvasive imaging failed to detect the severe stenosis of the right vertebral artery, which was revealed by invasive angiography. Finally, this case report underscores the significance of collaboration across several disciplines, such as cardiology, neurology, and radiology, as well as endovascular medicine in diagnosing and managing atypical manifestations of complex conditions.

Rotational Vertebral Artery Syndrome (Bow Hunter's Syndrome): A Rare Differential Diagnosis in Patients With Syncope.

Syncope is a common symptom in clinical practice. Rotational vertebral artery occlusion syndrome, also referred to as Bow Hunter's syndrome (BHS), is a rare condition associated with syncope and is caused by mechanical occlusion or stenosis secondary to mechanical compression of the vertebral artery during head rotation. BHS is associated with a multifactorial etiology; however, in most cases, this condition is attributed to degenerative changes. A 53-year-old man visited our hospital for the evaluation of fainting and dizziness episodes that occurred when he turned his head. Evaluation as an outpatient in the Department of Neurology showed a positive result on the Frenzel goggle test. Transfemoral cerebral angiography performed at the Department of Neurosurgery revealed stenosis of the proximal right vertebral artery. Complete occlusion of the vertebral artery was observed, and the head was turned to the right. Decompression and fusion were performed, and the contributory lesion was completely removed. Postoperative imaging confirmed complete removal of the spur and sufficient vertebral artery decompression; the patient's symptoms resolved postoperatively.

Balloon-hooking technique for stabilizing a guiding catheter in tortuous supra-aortic vessel: A case report.

Objective: When performing endovascular interventions for supra-aortic vessels, the tortuous vascular anatomy observed in patients with atherosclerotic lesions often limits the ability to maintain a stable guiding catheter position. Here, we report a case of right vertebral artery (VA) stenosis treated with transfemoral stenting and discuss the utility of balloon-hooking technique using partially inflated balloon for stabilizing the balloon guiding catheter (BCG) in the supra-aortic vessel. Case presentation: A 74-year-old man who underwent right carotid artery stenting, coronary artery bypass grafting, and bilateral iliac artery stenting was admitted to our emergency department because of dizziness related to head movement. Computed tomography angiography revealed right VA origin stenosis and left subclavian artery (SA) occlusion. The patient underwent stenting of the right VA. After several unsuccessful cannulation attempts into the right VA through transradial access, transfemoral access was obtained through the left iliac stent. A 9-Fr BGC was navigated into the right SA. The balloon was partially inflated just distal to the first curve of the right SA and used as hook by pulling back until the proximal edge of the balloon was pushed distally by the lesser curvature of the SA, resulting in stabilization of the BGC and successful angioplasty and stent deployment at the VA stenosis. The patient's symptoms resolved completely, without any neurological deficits. Conclusions: Balloon-hooking technique using a partially inflated BGC is feasible for stabilizing the guiding catheter in tortuous supra-aortic vessel.

Duplex Ultrasonography for the Evaluation of Extracranial Vertebral Artery: A Prospective Comparison With Digital Subtraction Angiography.

Background and Objective: Patients with symptomatic vertebral artery stenosis are at high risk of stroke recurrence, especially ≥70% stenosis. Revascularization may be considered for extracranial vertebral artery stenosis in patients with recurrent ischemic events despite optimal medical management. Currently, there is a lack of consensus on the ultrasonic evaluation of extracranial vertebral artery stenosis in clinical practice. This study aimed to validate the efficiency of duplex ultrasonography and assess the optimal sonographic thresholds for predicting extracranial vertebral artery stenosis. Methods: This is a prospective study of all patients with symptomatic posterior circulation stroke/transient ischemic attack who were scheduled to undergo digital subtraction angiography from April 2020 to October 2021. A total of 544 vertebral arteries with a normal lumen or extracranial stenosis confirmed with digital subtraction angiography were included in the study. The peak systolic velocity at the V1 segment (PSVv1) and the V2 segment (PSVv2) were measured and the PSVv1/PSVv2 and PSVv2/PSVv1 ratios were calculated. The cutoff values were determined using receiver operating characteristic analysis. Results: The areas under the receiver operating characteristic curve of all the velocity parameters to predict extracranial vertebral artery stenosis were >0.80. The cutoff values for predicting ≥50% and ≥70% V1 segment stenosis were PSVv1 ≥146 cm/s (sensitivity 76.2%, specificity 86.3%) and PSVv1/PSVv2 ratio ≥2.2 (sensitivity 84.3%, specificity 77.6%), and PSVv1 ≥184 cm/s (sensitivity 80.8%, specificity 87.1%) and PSVv1/PSVv2 ratio ≥3.5 (sensitivity 79.5%, specificity 90.5%), respectively. The cutoff values for predicting ≥50% and ≥70% V2 segment stenosis were PSVv2 ≥80 cm/s (sensitivity 75.0%, specificity 91.0%) and PSVv2/PSVv1 ratio ≥1.2 (sensitivity 75.0%, specificity 94.8%), and PSVv2 ≥111 cm/s (sensitivity 81.0%, specificity 95.0%) and PSVv2/PSVv1 ratio ≥1.7 (sensitivity 81.0%, specificity 96.6%), respectively. Conclusion: Symptomatic patients with the ultrasonic parameters of PSVv1 ≥146 cm/s and PSVv1/PSVv2 ratio ≥2.2 at V1 segment or PSVv2 ≥80 cm/s and PSVv2/PSVv1 ratio ≥1.2 at V2 segment need to be considered for further verification by digital subtraction angiography to seek revascularization. If the parameters increase to PSVv1 ≥184 cm/s and PSVv1/PSVv2 ratio ≥3.5 at the V1 segment or PSVv2 ≥111 cm/s and PSVv2/PSVv1 ratio ≥1.7 at the V2 segment, these patients have an increased risk of recurrent stroke and are more likely to need revascularization. The results can be used as a reference for the assessment and long-term management of patients with extracranial VA stenosis.