tandem occlusion of VERTEBRAL BASILAR ARTERY OCCLUSION

Acute cerebral infarction due to vertebral-basal artery occlusion in the posterior cerebral circulation often has non-specific onset symptoms like those in the anterior cerebral circulation, but causes death at a much higher rate.

1. MD. DR. TRANG MONG HAI YEN Cardio-vascular Intervention Department Head of Neuro-intervention Unit Thong Nhat Hospital – Viet Nam ACUTE POSTERIOR CIRCULATION STROKE with tandem occlusion

2. Posterior circulation stroke: 15 - 20% Stroke isolated with basal artery: 1- 4%

3. Presenting signs and symptoms in 407 patients with posterior circulation strokes (data from the New England Medical Centre Posterior Circulation Registry121). (BMJ 2018) Gargi Banerjee et al. BMJ 2018;361:bmj.k1185 ©2018 by British Medical Journal Publishing Group

4. Arch. Neurol. 2012;69(3):346-351. Publish online November 14,2011.doi:10.1001/archneurol.2011.2083

5. Nouh A, Remke J and Ruland S (2014) Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management.  Front. Neurol.   5 :30. doi : 10.3389/fneur.2014.00030

6. Akhtar N 1 ,  Kamran SI ,  Deleu D ,  D'Souza A ,  Miyares F ,  Elsotouhy A ,  Al-Hail H ,  Mesraoua B ,  Own A ,  Salem K ,  Kamha A ,  Osman Y . . Eur J Neurol.  2009 Sep;16(9):1004-9. doi : 10.1111/j.1468-1331.2009.02709.x. Epub 2009 Jun 15. Ischaemic posterior circulation stroke in State of Qatar.

7. Front. Neurol., 26 April 2019 |  https://doi.org/10.3389/fneur.2019.00417 Intravenous Thrombolysis in Posterior Circulation Stroke.  Tomáš Dorňák * , Michal Král , Daniel Šaňák , Petr Kaňovský

8. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke © 2018 American Heart Association, Inc. Stroke is available at http:// stroke.ahajournals.org                                                                                                               DOI: 10.1161/STR.0000000000000158

9. Male, 72yrs Dizziness increasing  unconsciousness at ER Onset  admission ER: 30mins G: 6 points (E1V4M1) CASE REPORT

10. No cerebral hemorrhage Absence of: - top part of BA - 2 vertebral arteries’ origins  Begin using rtPA  Consult with neuro-interventionist CTA RESULTS

11. Nearly occlusion at right vertebral artery origin DSA RESULTS

12. Nearly occlusion at left vertebral artery origin flow after LtVA origin is better than at the RtVA  doing thrombectomy from Lt side

13. Bullet technique: 1. Using 2.0 x 15mm balloon at low pressure to dilate the LtVA origin while pushing 088 Neuronmax long sheath in to Lt VA  fail balloon neuronmax MECHANICAL THROMBECTOMY PROCEDURE

14. 2. Using 2.0 x 15mm balloon to dilate the LtVA origin at low pressure while pushing Fragomax intermediate guiding catheter inside of neuronmax long sheath into Lt VA  fail neuronmax balloon Fragomax

15. 3. Using 3.0 x 15mm balloon at a high pressure (16atm), keep in 30 seconds Then, using 2.0 x 15mm balloon up at 6 atm while pushing Fragomax intermediate guiding catheter in to Lt VA via the balloon  success Neuronmax long sheath still could not go pass VA origin, just stayed in subclavien artery neuronmax Fragomax Rosuvastatin 40mg

16. Not able changing FRG to JET 7 to do aspiration  Pushing up FRG as higher as it could be Occlusion at the top of BA

17. Using rebar 2.4F go up to lesion at BA

18. using only stent retriever to pull the thrombosis down to FRG, while doing aspiration blood out continuously from FRG  BA and PCA revasculation – TIMI 3

19. checking again Lt VA origin every 5 mins x 2 times  blood flow still appears good  Stop Procedure  Total time of procedure: 28mins 17/12/2020

20. Extremely Stenosis at Rt internal Carotid

21. 31/03/2021 31/03/2021 Stenting Lt VA origin after 3 months Rosuvastatin DAPT