Discussion 63 y/o man with frequent episodes of dizziness and visual loss. Pt is on coumadin and ASA, but I think his symptoms are more hemodynamic than thromboembolic. He basically has a stenotic right vertebral origin with a chronically occluded mid-basilar and left vertebral. Fortunately, he has good sized PCOMs. I think that if his symptoms continue, I would be inclined to PTA that right vertebral origin and see how he does. Please email your comments and I will post them anonymously here so we all can learn something. If you prefer to not have your comments posted, please let me know. Follow-Up Turns out the patient has new insurance that doesn't include our facility... Your Comments |
Greatest risks come with blood pressure swings, downward.
Need to pay
attention to BP -- that it is not even given as part of profile
suggests that you are only looking at anatomy not physiology.
Even if you add some with right vert stenosis dilatation, BP is key.
Interesting that you don't show us selective left subclavian
reconstituting left vert by collaterals (only on MRA). Collaterals
beyond a proximal vertebral occlusion are rich, and would be rich for
right vert as it stenoses more. Interesting that you don't show us
collaterals from left occipital to left vert at C1 -- presumably
subclavian collaterals are already so good that there is not enough
pressure gradient from external to vert occipital to show that path.
BP needs to be understood (24 hour monitoring) and treated as
necessary. That will be a real treatment, maybe with anticoagulation,
to prevent catastrophe related to basilar occlusion. Goal of treatment
is to prevent clots forming adjacent to occluded segment; they are most
likely to form during low pressure states.
Vertebral stenosis dilatation has logic, may be useful if nothing bad
happens during the procedure, but will not prevent catastrophic stroke
if the patient is really suffering from hypotensive episodes.
I think I would ignore the basilar occlusion
since the distal
collateral looks so good. Regarding the Right Verterbral origin stenosis,
I
think that I would treat it if she has failed medical therapy. If she
has
not had a trial of dual anti-platelet meds or can't take them then
stenting would be a reasonable option. There is a high rate of
restenosis
at this site and I have started to use drug eluting stents for this
purpose. Of course, I can't advocate this off label use of a device but
it makes sense to me!
I would angioplasty and stent this stenosis. I have had
good luck with
Taxus stent in handful of cases in this location. I have had restenosis
rate similar to that of angioplasty alone with plain stents.
Did the individual fully
recover from their pontine stroke? Are they
experiencing further events on medication?