Thrombus in vertebrobasilar dolichoectatic artery treated with intravenousurokinase

Background: Vertebrobasilar dolichoectasia is often found in patients with posterior circulation ischemia. Brain ischemia is caused by abnormal flow i n the dilated artery and obstruction of paramedian arteries or intraluminal thrombus with artery-to-artery embolism. We report a patient with vertebro basilar dolichoectasia and luminal thrombus treated with intravenous urokin ase who did well but died 2 months later of subarachnoid hemorrhage. Case D escription: A 60-year-old man developed right-hand clumsiness, dysarthria a nd ataxia. Computed tomography showed vertebrobasilar dolichoectasia and th rombus in the basilar artery. Symptoms quickly resolved on heparin but recu rred on warfarin and again resolved on heparin. Two weeks later, while on w arfarin and aspirin 325 mg, he developed hand numbness, oscillopsia and ata xia. Symptoms again resolved on heparin. Angiography showed severe dolichoe ctasia of the distal right vertebral artery and basilar artery. A large mur al thrombus was detected in the ventral part of the distal basilar artery n arrowing the lumen by 50%. He was treated with intravenous urokinase 4,400 units/kg as a bolus followed by 4,400 units/kg/h for 12 h. Repeat angiograp hy showed almost complete recanalization and improved filling of basilar ar tery branches. He was maintained on warfarin and aspirin 81 mg and had no f urther ischemic episodes. He died 2 months later of rupture of the basilar artery and subarachnoid hemorrhage. Conclusion: Some patients with thrombos is of vertebrobasilar dolichoectactic arteries continue to have ischemic sy mptoms despite adequate anticoagulation. Intravenous thrombolysis may be ef fective in reducing the risk of stroke, but the risk/benefit ratio needs to be assessed in each patient.