Cerebral angiography directly visualizes to‐and‐fro stream of vertebral artery stump syndrome

Vertebral artery stump syndrome is one of the minor causes (1.4%) of ischemic stroke in posterior circulation region.1,2 A seventyfiveyearold man repeated ischemic stroke three times for 7 days in posterior circulation area. Head magnetic resonance imaging (MRI) of diffusionweighted image (DWI) revealed cerebral infarction at right cerebellum around the posterior inferior cerebellar artery (PICA) area (first time; Figure 1), right posterior cerebral artery (PCA) area (second time; Figure 1), and right lateral medullary (third time; Figure 1), respectively. D dimer in serum was 1.2 μg/mL. Abnormal myocardial motion by echocardiogram and atrial fibrillation (Af) by electrocardiogram were not detected. Cerebral angiography, using 4French Simons form catheter, revealed toandfro stagnated flow in right vertebral artery (Figure 2, arrow). Right VA first segment almost occluded (computed tomography angiography; data not shown). Blood flow came in right VA (Figure 3, arrow) through muscle branch of occipital artery (Figure 3, arrow head). The collateral flow of right VA and reverse flow from left VA formed toandfro stasis. Intravessel red fibrin thrombus was presumed to cause repeatable and multiple cerebral infarctions. Like this presentation case, VA stump syndrome often brings recurrent ischemic stroke in posterior circulation area.1,2 Although endovascular intervention on VA origin occlusion is one of surgical therapy,2 widerange occlusion or dissection of VA is challenging to treat. Not antiplatelet but anticoagulation therapy is useful to prevent stroke by VA stump syndrome.3 Because of long lesion of right VA, this patient started oral anticoagulant therapy (warfarin) without endovascular intervention.3 Recurrent infarction was not observed. Flow stasis with toandfro stream in VA was directly detected by cerebral angiography. Although angiography is invasive, it is useful to diagnose VA stump syndrome. Clinical symptoms of