A 55-year-old male with a history of hypertension and diabetes presented with sudden-onset vertigo, accompanied by nausea and vomiting, lasting for over 10 hours. Initial neurological examination revealed a National Institutes of Health Stroke Scale (NIHSS) score of 1. Emergency CT angiography (CTA) showed occlusion of the left vertebral artery at its origin (dominant side) and the intracranial segment of the right vertebral artery (nondominant side) (Figure 1(A)). The patient was started on dual antiplatelet therapy, including 300 mg of clopidogrel and 100 mg of aspirin, along with intensified statin therapy. Despite this, 40 hours later, his condition deteriorated with the sudden onset of impaired consciousness, resulting in an NIHSS score of 16. Follow-up CTA revealed occlusion of the upper segment of the basilar artery (Figure 1(C)).

Figure 1.

Progressive ischemic stroke in a patient with vertebral artery stump syndrome. (A) Initial CT angiography (CTA) reveals occlusion of the left vertebral artery V1–V2 segments with an intact basilar artery (white arrow). (B) Early CT shows cerebellar infarction. (C) Follow-up CTA, after disease progression, reveals occlusion of the upper segment of the basilar artery (white arrow). (D) A long segment of low-density lesion in the left vertebral artery V1–V2 segment, suspected to be a thrombus. (E) Three months later, follow-up CTA shows patency of the stent in the left vertebral artery origin.

The patient’s initial presentation was most likely due to thromboembolic occlusion of the cerebellar branches (Figure 1(B)). The subsequent clinical deterioration could be attributed to the migration of a thrombus from the residual lumen of the left vertebral artery into the basilar artery (Figure 1(C)–(D)). The dual antiplatelet regimen and intensified statin therapy may have facilitated the displacement of the residual thrombus. In light of these findings, the patient underwent endovascular thrombectomy. Preoperative angiography revealed hypoplasia of the right vertebral artery and complete occlusion of the left vertebral artery, with faint opacification of the left vertebral artery V2 segment (Figure 2(A)–(C)). An 8-French catheter, coaxial with a 5-French catheter, was placed in the left subclavian artery. Despite multiple attempts at antegrade recanalization, the left vertebral artery could not be recanalized due to the absence of a distal stump. Consequently, retrograde recanalization was attempted through the deep cervical artery (Figure 2(D)–(F)). Access to the left vertebral artery V2 segment was successfully achieved, and a 6-French aspiration catheter was used to remove the distal thrombus. Post-procedural angiography demonstrated complete restoration of basilar artery flow, with the deployment of a stent in the left vertebral artery origin (Figure 2(G)–(I)). Three months following the procedure, the patient had recovered well, with an Modified Rankin Scale score of 1, and follow-up CTA confirmed patency of the left vertebral artery stent (Figure 1(E)).

Figure 2.

Angiographic images in a patient with vertebral artery stump syndrome. (A) Angiography reveals right vertebral artery hypoplasia with occlusion of the intracranial segment. (B) Occlusion of the left vertebral artery V1–V2 segment with no visible distal stump, with opacification of the deep cervical artery (white arrow) and ascending cervical artery (black arrow). (C) Late arterial phase shows faint opacification of the left vertebral artery V2 segment (black arrow). (D) Antegrade recanalization is unsuccessful, remaining within the false lumen. (E) A 0.010-inch Sychron guidewire, with the assistance of an SL-10 microcatheter, successfully navigates retrogradely through the collateral vessels to the V2 segment of the vertebral artery. (F) The wire is exchanged for a 300 cm, 0.014-inch Transend guidewire, with additional support from a V18 wire, to successfully navigate through the occluded segment of the vertebral artery and perform angioplasty. (G) An aspiration catheter successfully reaches the upper basilar artery and removes the thrombus. (H) Angiography demonstrates complete restoration of basilar artery flow. (I) A stent is deployed at the left vertebral artery origin.

Vertebral artery stump syndrome is a rare cause of posterior circulation ischemic stroke, with an incidence of approximately 1.4% ^{Reference Kawano, Inatomi, Hirano and Yonehara1} among patients with acute posterior circulation ischemia. After vertebral artery occlusion, collateral circulation may be established through branches such as the deep cervical artery, ascending cervical artery and occipital artery. The deep cervical artery typically arises from the cervicothoracic trunk, while the ascending cervical artery originates from the thyrocervical trunk. Recurrent embolic events in the setting of arterial occlusion may occur due to stasis and embolization of thrombotic fragments, leading to further ischemic events. Treatment options include antiplatelet and anticoagulant therapy, endovascular interventions and surgical approaches. ^{Reference Nguyen, Raymond, Mahmoud, Weill, Roy and Guilbert2} In this case, the patient’s condition progressed due to acute thromboembolism in the upper basilar artery. The inability to perform antegrade recanalization, as no distal stump was present, necessitated the use of retrograde recanalization. This strategy, followed by successful endovascular thrombectomy, effectively prevented recurrent ischemic events.