Indirect Reperfusion in the Setting of Symptomatic Carotid Occlusion by Treatment of Bilateral Vertebral Artery Origin Stenoses

Background: Patients with total carotid occlusions can develop ischemic stroke as a result to hemodynamic impairment. Flow augmentation can be provided through a variety of surgical and endovascular techniques. We describe a patient treated with vertebral artery stent placement to augment indirect flow to the territory of an occluded carotid artery. Methods: A 52-year-old man presented with ST elevation myocardial infarction and ischemic stroke manifesting with right-sided hemiparesis and aphasia. A computed tomography (CT) angiogram confirmed the presence of a left internal carotid artery total occlusion with prolongation of the mean transit time and reduced estimated cerebral blood flow on CT perfusion maps. The patient was taken for angiography and found to have bilateral vertebral artery ostial stenosis and a posterior communicating artery supplying the left hemisphere. Results: The patient underwent successful stenting and angioplasty of both lesions with stabilization of neurologic symptoms. A follow-up CT perfusion study showed marked improvement in the estimated cerebral blood flow, and reduction of the mean transit time. Conclusions: Stenting and angioplasty of a stenosis of an artery providing indirect blood flow to the territory of an occluded ipsilateral vessel can stabilize neurologic decline and improve CT perfusion parameters.