Proximal Vertebral Artery Atheromatosis Causing Embolic Occlusion of the Right Posterior Cerebral Artery: Catheter Dilatation of the Proximal Vertebral Artery and Mechanical Thrombectomy of the Posterior Cerebral Artery

Posterior cerebral artery (PCA) ischemic strokes have a different clinical presentation from carotid territory strokes, with specific neurological and cognitive deficits. Although often considered less disabling, PCA strokes can result in neuropsychological deficits, particularly in attention, executive function, and anterograde memory, as well as visual symptoms that can significantly impact a patient’s functional independence and quality of life. Vertebral artery (VA) ostial stenosis is implicated in one-fifth of all posterior circulation cerebrovascular accidents. We present the case of a 72-year-old woman with an unremarkable medical history except for hypertension and dyslipidemia, who was admitted to the emergency department (ED) after developing unusual behavior, incoherent speech, confusion, visual changes, and left hemibody weakness. She was reportedly well 4 h prior to the changes and was admitted to the hospital with an initial National Institutes of Health Stroke Scale (NIHSS) score of 12. Her daughter reported that the patient had recently undergone routine blood tests and gynecologic and cardiologic studies (including echocardiogram and Holter), which were unremarkable. While the results of a noncontrast head CT showed only microvascular disease, automated CT perfusion (CTP) and CT angiography (CTA) studies showed hypoperfusion of the right temporomesial and occipital regions and occlusion of the proximal segment of the right posterior cerebral artery (PCA), respectively, Intravenous thrombolysis was not administered. Under general anesthesia, neuroangiography showed ulcerative stenosis of the origin of the left VA and occlusion of the proximal right PCA. The patient underwent successful and uneventful endovascular revascularization of the right PCA and effective catheter dilatation of the left VA ostial lesion. Antiplatelet therapy with aspirin and clopidogrel was initiated at the end of the procedure. The patient was extubated 2 h later and evaluated by neurologists 6 h after the procedure. She showed significant neurological improvement with an immediate post-extubation NIHSS of 2. Postoperative CT showed no hemorrhage. The patient was discharged home after 5 days with an NIHSS of 1 and a modified Rankin Scale (mRS) score of 0. We discuss the clinical prognosis of isolated PCA occlusions, conflicting recommendations for PCA management, the improved efficacy of new stent retrievers, the implications of proximal VA stenosis, and the usefulness of an old and forgotten angioplasty technique described by Charles Kerber in 1980 as “catheter dilatation.”