Tandem intracranial stent deployment for treatment of an iatrogenic, flow-limiting, basilar artery dissection: Technical case report

OBJECTIVE AND IMPORTANCE: Intimal dissection constitutes one of the complic ations associated with angioplasty of intracranial vessels. We present a ca se of iatrogenic dissection of the entire basilar artery, which was induced by angioplasty and stenting of symptomatic, focal, intracranial vertebral artery stenosis, and its successful treatment with tandem deployment of a d ownstream stent. CLINICAL PRESENTATION: A 61-year-old, hypertensive, renal transplant recipi ent presented with orthostatic vertebrobasilar insufficiency that was refra ctory to medical management, including anticoagulation therapy. Angiography revealed an occluded right vertebral artery and focal, high-grade, left in tracranial vertebral artery stenosis. Magnetic resonance imaging showed mul tiple posterior fossa infarctions. The left intracranial vertebral artery s tenosis was successfully treated with primary stent deployment and balloon angioplasty, with symptom resolution. On postprocedure Day 2, the patient n oted worsening right hemiparesis. INTERVENTION: Subsequent angiography revealed a flow-limiting, windsock-typ e, basilar artery dissection beginning at the distal end of the left verteb ral artery stent and extending to the origin of the left posterior cerebral artery. A tandem stent was navigated intracranially and deployed past the first one, successfully sealing the dissection inflow zone and reconstituti ng normal flow to the top of the basilar artery. A clinical follow-up exami nation at 3 months revealed no further orthostatic symptoms and only mild r esidual right-sided weakness. CONCLUSION: This is the first description of iatrogenic stent-induced disse ction of the entire basilar artery that was successfully treated by inflow zone control via tandem intracranial stent deployment.