Endovascular Revascularization for Chronic Vertebral Artery Occlusion with Poor Collateral Circulation and a Large Perfusion Abnormality Identified by Automated Perfusion Imaging: A Case Report.

OBJECTIVE: Endovascular revascularization is increasingly used to treat symptomatic acute intracranial vertebral artery (ICVA) occlusion, with reported clinical benefit. In contrast, chronic total occlusion (CTO) is managed primarily with conservative therapy, and the indications for and efficacy of endovascular revascularization remain uncertain.

CASE PRESENTATION: A 74-year-old man with right vertebral artery (VA) occlusion and left VA stenosis was followed at our outpatient clinic. He presented with a 40-day history of dizziness and gait disturbance. MRI showed no new acute infarction, whereas MRA demonstrated bilateral VA occlusion. However, automated perfusion imaging (RAPID; iSchemaView, Golden, CO, USA) identified a large perfusion abnormality, leading to a diagnosis of symptomatic ICVA CTO. Urgent endovascular revascularization was performed. A small postoperative cerebellar infarction developed without new neurological deficits. Symptoms on admission improved with medical therapy and rehabilitation, and he was discharged home 14 days after the procedure; the perfusion abnormality had nearly resolved. At 2 months after hospital discharge, the patient remained asymptomatic, with no symptom recurrence.

CONCLUSION: Endovascular revascularization for symptomatic ICVA CTO resulted in a favorable outcome. Automated perfusion imaging may help identify appropriate candidates for this treatment.