Proximal Vertebral Artery and Basilar Artery Stenoses, Followed by Basilar Artery Thrombosis; Repeated Stenting and Angioplasty Procedures, and Dissolution of a Large Nonocclusive Basilar Artery Thrombus with Extended Intravenous Infusion of Eptifibatide, with Good Clinical Outcome

An 82-year-old man with a history of arterial hypertension for several years prior and an episode of dizziness and anomic aphasia 3 years prior presented to the referring hospital with transient episodes of dizziness, dysarthria, and partial left facial nerve palsy. DSA revealed proximal stenoses of both vertebral arteries (VAs) and a high-grade midbasilar artery (BA) stenosis. The first endovascular treatment comprised stent-assisted percutaneous transluminal angioplasty of both VAs with drug-eluting coronary stents and the BA (Enterprise) in March 2018. In-stent stenoses of the right VA and the BA required three retreatments with balloon dilatations. Approximately 1 year after the fourth treatment, an acute right V4 occlusion was diagnosed, and the left V4 segment was shown to end in the posterior inferior cerebellar artery. Endovascular treatment included balloon dilatation of the BA, aspiration thrombectomy, and implantation of a Solitaire stent into the BA. Attempted aspiration of a large nonocclusive thrombus in the distal BA failed. The patient received acetylsalicylic acid, ticagrelor, body weight-adapted eptifibatide IV infusion, and subcutaneous low-dose low molecular weight heparin for 5 days. This regimen resulted in complete dissolution of the large thrombus in the BA and clinical recovery. The main topic of this chapter is the dissolution of nonocclusive thrombi in the neurovasculature with extended eptifibatide IV infusion, dual platelet function inhibition, and low-dose heparin administration.