PMC10196394_01
(A) Acute infarction of the right anteromedial medulla oblongata visualized by MRI (diffusion-weighted imaging). (B) Computed tomography angiography image showing the bilateral VA stenosis in the intracranial segment (arrow). (C) Left vertebral angiogram (anterior-posterior view) showing preocclusive stenosis of the left intracranial VA (arrow). (D) Tortuosity of the left VA revealed by angiogram. (E) Computed tomography perfusion showing the marked hypoperfusion in the brain stem and cerebella (Tmax). (F) High-resolution MRI showing atheromatous plaques (arrow) in the stenotic segment of the left VA (coronal view). MRI, magnetic resonance imaging; VA, vertebral artery; Tmax, Time to Max.
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MRI demonstrated a new-onset ischemic stroke in the right anteromedial medulla oblongata (Figure 1A) and an old hemorrhage in the right medial pons. Computed tomography angiography (CTA) revealed bilateral VA stenosis in the intracranial segment (Figure 1B). Later digital subtraction angiography (DSA) confirmed this result, demonstrating a preocclusive (> 90%) narrowing of the left intracranial VA and tortuosity of the left VA (Figures 1C,D). We also found marked hypoperfusion in the brain stem and cerebella by computed tomography perfusion (Figure 1E). High-resolution MRI revealed atheromatous plaques in the stenotic segment of the left VA (Figure 1F).
(A) Angiography with DAC in the distal V2 segment revealing severe stenosis (asterisk), dysplasia in the left PICA (arrow), and anastomosis supplying blood flow from the left VA to the cervical cord (arrowhead). (B) Left vertebral angiogram showing the venous phase of the intracranial anatomy and left VA flow arrest. (C) Post-angioplasty angiography revealing the improvement of the stenosis (arrow) and marked spasm of the left V3 segment (arrow-head). (D) Roadmap after intra-artery nimodipine showing the spasm mitigation process. (E) Control run after the deployment of Enterprise stent showing the patency of the left VA and PICA (arrow). (F) The final run showing the minor spasms in the initial segment of the left VA (arrow). DAC, Distal Access Catheter; PICA, Posterior Inferior Cerebellar Artery; VA, Vertebral Artery.
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AXS Catalyst 5 distal access catheter (DAC) (Stryker Neurovascular, Michigan, USA) in the distal V2 segment revealed severe stenosis, dysplasia in the left posterior inferior cerebellar artery (PICA), and anastomosis supplying blood flow from the left VA to the cervical cord (Figure 2A). A concomitant clear visualization of the left VA and venous phase of the intracranial anatomy suggested that the DAC incompletely blocked blood flow (Figure 2B). A 2.25 x 9 mm Gateway balloon catheter (Stryker Neurovascular, Fremont, CA, USA) was delivered over a 300 cm synchro2 microguidewire (Stryker Neurovascular, Salt Lake, Utah, USA) to the site and slowly dilated to 7 atm. Post-angioplasty angiography revealed improvement of the stenosis and marked spasm of the left V3 segment (Figure 2C). The slow infusion of 1 mg of intra-artery nimodipine alleviated the spasms (Figure 2D). The DAC was withdrawn immediately after the control run (Figure 2E). The final run showed only minor spasms in the initial segment of the left VA (Figure 2F).
(A) MRI (diffusion-weighted imaging) on the first day after the operation showing the acute infarction of the left posterior medulla oblongata. (B) Postoperative angiogram showing the intact vertebrobasilar arteries and patency of the left VA, left PICA (arrow), and implanted stent (arrowhead). (C) MRI (T2 and FLAIR images) on the fourth day after the operation revealing profound hyperintensity in the left medulla oblongata. (D) Cervical spine MRI on the fifth day after the operation revealing similar hyperintensity and swelling in the cervical cord (T2). (E, F) Ten days after the operation, MRI still revealed hyperintensity in the medulla oblongata and cervical cord. MRI, magnetic resonance imaging; VA, Vertebral Artery; PICA, Posterior Inferior Cerebellar Artery; FLAIR, Fluid-Attenuated Inversion Recovery.
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Again, CT imaging showed no marked changes, while MRI revealed acute infarction of the left posterior medulla oblongata on the next morning (Figure 3A). Subsequent DSA demonstrated intact vertebrobasilar arteries and patency of the left VA, left PICA, and implanted stent (Figure 3B). The patient received an intravenous injection of 40 mg methylprednisolone twice per day, along with glycerol fructose and edaravone injections. Three days later, T2 and Flair images showed more profound hyperintensity in the left medulla oblongata (Figure 3C). One day later, a cervical spine MRI (T2 images) revealed unexpected findings of similar hyperintensity and swelling in the cervical cord (Figure 3D). Ten days after the operation, MRI still showed marked hyperintensity in the medulla oblongata and cervical cord, while the patient's symptoms and neurologic deficits gradually improved (Figures 3E,F).
(A, B) At the 1-year follow-up, MRI (T2) showed normal intensity in the medulla oblongata and cervical cord. (C) Computed tomography angiography revealing the patency of both VAs (arrow). MRI, magnetic resonance imaging; VA, Vertebral Artery.
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At the 1-year follow-up, MRI showed normal intensity in the medulla oblongata and cervical cord, except for the old lesions (Figures 4A,B). Both VAs remained patent on the CTA (Figure 4C).