Progressive Vertebrobasilar Stroke After Bilateral Vertebral Artery Occlusion and Severe Vertebrobasilar Stenosis: Revascularization of the Occluded Left Vertebral Artery After “Drilling in the Dark” with High Tip-Stiffness Microguidewires and Extra-Intracranial Angioplasty and Stenting, with an Unexpected Favorable Outcome

A “progressive stroke” is a progressive or gradual worsening of neurological function after the onset of ischemic stroke that persists over time until more severe neurological deficits appear. At the beginning of the process, there may be only prodromal symptoms (dizziness, headache, mild numbness, and weakness of the limbs). As symptoms progress, consciousness level can deteriorate to coma. The natural history of acute basilar artery occlusion is devastating and associated with the highest mortality and morbidity among strokes attributable to intracranial large-vessel occlusions. Basilar hypoperfusion is a less frequent and less studied condition with a similarly grim evolution and prognosis. Endovascular therapy has been proven to be more effective and safer than medicinal therapy for progressive stroke in patients with basilar artery compromise, and every effort should be made to obtain rapid and complete arterial recanalization. An 83-year-old man with a history of ischemic heart disease presented with medicinally controlled hypertension, dyslipidemia, borderline diabetes, and peripheral vascular disease. He was brought to the emergency room after suffering sudden onset dizziness and unsteady gait when he stood and rose quickly after lying down. During the neurological examination, there was horizontal nystagmus, persistent dizziness, bilateral Babinski sign, and quadriparesis with more pronounced left-sided weakness. CT and CT angiography (CTA) confirmed advanced microvascular brain disease, middle cerebellar peduncle stroke, and advanced intracranial vertebrobasilar (VB) atherosclerotic disease with occlusion of the distal right vertebral artery (VA) and severe stenosis of the left VB junction. The patient was started on aspirin and clopidogrel. After 3 days he became drowsy, and his left hemiparesis worsened. Cranial CT revealed progression of the middle cerebellar peduncle infarct, and CTA showed progression of the distal left VA-VB stenosis to complete occlusion and nonvisualization of the basilar trunk. Angiography confirmed a chronic occlusion of the proximal left VA. The origin of the artery was not visualized. The right vertebral artery showed chronic occlusion of the distal V4 segment beyond the posterior inferior cerebellar artery (PICA) origin. The right VA supplied the distal half of the left V2 segment via multilevel segmental intervertebral anastomoses. The left V2 artery then supplied the V3 and V4 segments. A severe atherothrombotic stenosis of the VB junction was unveiled. The basilar trunk was only faintly visible. Attempts to gain access to the left V2 segment using typical maneuvers and to the basilar trunk via the right V4 occlusion were unsuccessful. We placed an 8F guiding catheter in close contact with the upper wall of the left subclavian artery proximal to the thyrocervical artery. We pierced the angiographically occult and occluded VA ostium with a high tip-stiffness cardiological microguidewire with a 17 microcatheter. We succeeded in drilling through the V1 occlusion and placed the 17 microcatheter at the patent V2 segment. The microcatheter was exchanged for angioplasty balloons. Angioplasty maneuvers at V1 and proximal V2 were followed by V1-V2 stent-assisted angioplasty and, finally, stenting of the VB junction. Revascularization of the left VA and normalization of the basilar circulation were achieved. At 90 days, he scored 1 on the modified Rankin Scale (mRS). Revascularization of the basilar trunk is paramount, and every effort should be made to accomplish this objective. This unusual case describes a poorly explored endovascular technique using stiff-tip microguidewires usually designed for the management of coronary chronic total occlusions, with remarkable angiographic and clinical results. Alternative techniques for VB revascularization are the main topic of this chapter.