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CC BY 4.0 · Arq Neuropsiquiatr 2025; 83(05): s00451806833
DOI: 10.1055/s-0045-1806833
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Unmasking vertebral artery stump syndrome in recurrent posterior strokes treated with endovascular therapy

Leonardo Furtado Freitas 
1   Baptist Health of South Florida, Radiology Associates of South Florida, Miami FL, United States.
2   Florida International University, Herbert Wertheim College of Medicine, Miami FL, United States.
,
Kevin J. Abrams 
3   Baptist Health South Florida, Department of Radiology, Division of Clinical Neuroradiology, Miami FL, United States.
,
Márcio Luís Duarte 
4   Universidade de Ribeirão Preto, Departamento de Radiologia, Guarujá SP, Brazil.
5   Diagnósticos da América S.A., São Paulo SP, Brazil.
,
Guilherme C. Dabus 
6   Baptist Health South Florida, Department of Radiology, Division of Interventional Neuroradiology, Miami FL, United States.
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A 64-year-old male patient with hypertension and hyperlipidemia presented with sudden left eye vision loss. Imaging ([Figures 1] [2] [3] [4]) revealed recurrent posterior circulation infarcts and vessels occlusions. Angiography confirmed vertebral artery stump syndrome (VASS). An endovascular intervention successfully achieved complete recanalization without residual stenosis. The patient was discharged neurologically stable.

Zoom Image
Figure 1 Magnetic resonance imaging (MRI) scan of the brain, axial diffusion sequence. (A–E) Multiple acute/subacute infarcts in the posterior circulation (red arrows), involving the cerebellum and the right mesial temporo-occipital region. (F) Follow-up imaging performed seven days later, showing a new vascular event in the mesial right occipital lobe (yellow arrow).
Zoom Image
Figure 2 Computed tomography angiography (CTA) scan of the head, coronal maximum intensity projection (MIP) reconstruction with zoom-in of the vertebrobasilar system. (A,B) Images obtained seven days apart , showing an interval occlusion in the mid-to-distal segment of the right superior cerebellar artery (blue circles and arrows).
Zoom Image
Figure 3 (A) Computed tomography angiography (CTA) scan exhibiting normal right vertebral artery (VA). (B) Initial intracranial angiography of the right VA reveals normal intracranial flow and retrograde opacification of the intracranial left VA. Note that the right superior cerebellar artery is normal (arrow). (C,D) Left subclavian angiography depicts near-occlusion of the left VA origin with occlusion of its proximal V1 segment (arrows). Selective angiography of the left deep cervical artery in the frontal (E) and lateral (F) projections illustrate collateral supply to the distal V2 and V3 segments of the left VA via muscular anastomotic branches (arrows).
Zoom Image
Figure 4 (A) Repeat cerebral angiography 3 days later revealing a new occlusion of the right superior cerebellar artery (arrow). The decision was then made to attempt recanalization of the left VA. (B) A balloon guide catheter was positioned in the proximal left subclavian artery where the balloon was inflated to arrest antegrade flow and prevent distal embolization (single arrow); a balloon-expandable stent was then advanced and successfully deployed (double arrows). (C) The balloon of the balloon guide catheter was then deflated, and the final angiography confirms successful recanalization of the left VA.

Vertebral artery stump syndrome is a rare but treatable cause of recurrent posterior strokes,[1] [2] [3] with key mechanisms including stagnant blood flow leading to thrombus formation, propagation of embolic fragments from the occlusion's distal limit, and emboli introduced via collateral pathways.[4] This case highlights the importance of endovascular treatment in preventing neurological deterioration and improving outcomes.


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Conflict of Interest

The authors have no conflict of interest to declare.

Authors' Contributions

Conceptualization: LFF, KJA, MLD; Data curation: LFF, KJA; Formal analysis: LFF, KJA; Investigation: LFF, GCD; Methodology: LFF, GCD; Funding acquisition: KJA; Project administration: LFF, GCD; Resources: LFF; Software: LFF; Supervision: LFF, KJA, GCD; Validation: LFF, KJA, GCD; Visualization: LFF, KJA, GCD; Writing - original draft: LFF, KJA, MLD, GCD; Writing - review & editing: LFF, KJA, MLD, GCD.


Editor-in-Chief: Ayrton Roberto Massaro.


Associate Editor: Luis Filipe de Souza Godoy.


  • References

  • 1 Rossi SS, Iaccarino G, Bonura A. et al. Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options. J Stroke Cerebrovasc Dis 2024; 33 (08) 107819 . Epub 2024 Jun 13. PMID: 38878845
    CrossrefPubMedSearch in Google Scholar
  • 2 Ji R, Li B, Xu Z. Retrograde recanalisation for vertebral artery stump syndrome: a case report. Stroke Vasc Neurol 2022; 7 (05) 462-464 . Epub 2022 Mar 30. PMID: 35354663; PMCID: PMC9614125
    CrossrefPubMedSearch in Google Scholar
  • 3 Zhang W, Wang S, Li C. et al. A Case Series and Literature Review of Vertebral Artery Stump Syndrome. Front Neurol 2022; 12: 770845 . PMID: 35153978; PMCID: PMC8831726
    CrossrefPubMedSearch in Google Scholar
  • 4 Suzuki M, Dembo T, Hara W. et al. Vertebral artery stump syndrome. Intern Med 2018; 57 (05) 733-736
    CrossrefPubMedSearch in Google Scholar

Address for correspondence

Leonardo Furtado Freitas

Publication History

Received: 12 December 2024

Accepted: 13 February 2025

Article published online:
01 June 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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Bibliographical Record
Leonardo Furtado Freitas, Kevin J. Abrams, Márcio Luís Duarte, Guilherme C. Dabus. Unmasking vertebral artery stump syndrome in recurrent posterior strokes treated with endovascular therapy. Arq Neuropsiquiatr 2025; 83: s00451806833.
DOI: 10.1055/s-0045-1806833

  • References

  • 1 Rossi SS, Iaccarino G, Bonura A. et al. Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options. J Stroke Cerebrovasc Dis 2024; 33 (08) 107819 . Epub 2024 Jun 13. PMID: 38878845
    CrossrefPubMedSearch in Google Scholar
  • 2 Ji R, Li B, Xu Z. Retrograde recanalisation for vertebral artery stump syndrome: a case report. Stroke Vasc Neurol 2022; 7 (05) 462-464 . Epub 2022 Mar 30. PMID: 35354663; PMCID: PMC9614125
    CrossrefPubMedSearch in Google Scholar
  • 3 Zhang W, Wang S, Li C. et al. A Case Series and Literature Review of Vertebral Artery Stump Syndrome. Front Neurol 2022; 12: 770845 . PMID: 35153978; PMCID: PMC8831726
    CrossrefPubMedSearch in Google Scholar
  • 4 Suzuki M, Dembo T, Hara W. et al. Vertebral artery stump syndrome. Intern Med 2018; 57 (05) 733-736
    CrossrefPubMedSearch in Google Scholar

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Zoom Image
Figure 1 Magnetic resonance imaging (MRI) scan of the brain, axial diffusion sequence. (A–E) Multiple acute/subacute infarcts in the posterior circulation (red arrows), involving the cerebellum and the right mesial temporo-occipital region. (F) Follow-up imaging performed seven days later, showing a new vascular event in the mesial right occipital lobe (yellow arrow).
Zoom Image
Figure 2 Computed tomography angiography (CTA) scan of the head, coronal maximum intensity projection (MIP) reconstruction with zoom-in of the vertebrobasilar system. (A,B) Images obtained seven days apart , showing an interval occlusion in the mid-to-distal segment of the right superior cerebellar artery (blue circles and arrows).
Zoom Image
Figure 3 (A) Computed tomography angiography (CTA) scan exhibiting normal right vertebral artery (VA). (B) Initial intracranial angiography of the right VA reveals normal intracranial flow and retrograde opacification of the intracranial left VA. Note that the right superior cerebellar artery is normal (arrow). (C,D) Left subclavian angiography depicts near-occlusion of the left VA origin with occlusion of its proximal V1 segment (arrows). Selective angiography of the left deep cervical artery in the frontal (E) and lateral (F) projections illustrate collateral supply to the distal V2 and V3 segments of the left VA via muscular anastomotic branches (arrows).
Zoom Image
Figure 4 (A) Repeat cerebral angiography 3 days later revealing a new occlusion of the right superior cerebellar artery (arrow). The decision was then made to attempt recanalization of the left VA. (B) A balloon guide catheter was positioned in the proximal left subclavian artery where the balloon was inflated to arrest antegrade flow and prevent distal embolization (single arrow); a balloon-expandable stent was then advanced and successfully deployed (double arrows). (C) The balloon of the balloon guide catheter was then deflated, and the final angiography confirms successful recanalization of the left VA.