Symptomatic non-atherosclerotic bilateral extracranial vertebral artery occlusion treated with extracranial to intracranial bypass: case report

Abstract

-Posterior fossa ischemia is not a very frequent situation. It is responsible for about 25% of all ischemic strokes, and the vast majority of the cases are related to atherosclerotic stenosis of the vertebral and/or basilar arteries. Acute ischemia can also occur in the setting of vertebral art e ry dissection, traumatic or spontaneous. Recently, blunt trauma has been increasingly recognized as a cause for craniocerv i c a l a rt e ry injury. The management options for both traumatic and athero s c l e rotic lesions of the posterior fossa are still under debate. We present a case of a delayed onset of hemodynamic ischemic symptoms due to bilateral vertebral art e ry occlusion probably related to remote trauma to the head and neck in a 55-year-old-man treated successfully with extracranial to intracranial bypass.KEY WORDS: EC-IC bypass, ischemic stroke, surgical revascularization.Oclusão sintomática não-aterosclerótica da artéria vertebral extracraniana tratada com bypass: relato de caso RESUMO -Acidentes vasculares cerebrais (AVC) isquêmicos no sistema vert e b ro-basilar não são fre q u e n t e s . R e p resentam cerca de 25% dos AVCs isquêmicos, e a maioria é relacionada com atero s c l e rose das art é r i a s v e rtebrais e/ou basilar. Isquemia aguda pode também ser resultado de dissecções da artéria vert e b r a l , traumáticas ou espontâneas. Recentemente, traumatismos fechados têm sido cada vez mais re c o n h e c i d o s como causa de lesão das artérias craniocervicais, podendo ou não resultar em sintomas isquêmicos. O tratamento para estas lesões, sejam traumáticas ou ateroscleróticas, ainda é motivo de debate. Relatamos o caso de um homem de 55 anos com sintomas isquêmicos, hemodinâmicos, tardios, devido a oclusão bilateral das artérias vertebrais, provavelmente relacionada a lesão traumática das artérias vertebrais, tratada com sucesso com bypass extra-intracraniano. PALAVRAS-CHAVE: bypass, isquemia cerebral, revascularização intracraniana.Posterior fossa ischemia is not a very frequent situation. It is responsible for about 25% of all ischemic s t rokes, the vast majority related to athero s c l e ro t i c stenosis of the vertebral and/or basilar arteries. Blunt trauma to the head and neck is being recognized as a cause of carotid and vertebral art e ry injury, most c o m m o n l y, carotid dissections. Since its institution in the 50s, anticoagulation has been the main stem of medical management of vert e b ro-basilar insuff i c i e nc y. The use of surgical means to treat intracranial ischemic symptoms has been disfavored since the EC-IC bypass study, although the surgical treatment of v e rt e b robasilar insufficiency can be considered in cases where there is no response to maximal medical therapy and no endovascular options. We present a case w h e resurgical treatment of posterior fossa ischemia resulted in complete resolution of symptoms. CASEA 55 years-old man was re f e rred to evaluation of neuro s u rgical treatment options from a stroke neurologist. His past medical history was u...