Contralateral middle cerebral artery embolization following transradial vertebral artery stenting: a case report

Transradial vertebral artery (VA) stenting is an effective, and relatively safe treatment for symptomatic extracranial VA stenosis-the main cause of posterior circulation ischemia. Still, rare non-target anterior circulation cerebral embolisms can occur intraoperatively.

A 63-year-old male with prior cerebral infarction (NIHSS score 0, mRS score 1) presented with recurrent dizziness. Pre-admission CTA imaging confirmed severe (> 70%) bilateral VA ostial stenosis. The patient underwent right transradial VA stenting. Ten minutes post-procedure, he developed altered consciousness, mixed aphasia, and right hemiplegia (NIHSS score 16). Angiography confirmed acute occlusion in the M2 segment of the left middle cerebral artery (MCA). Mechanical thrombectomy was attempted but terminated due to severe vascular tortuosity, with no recanalization achieved. Immediate postoperative CT revealed contrast extravasation (CE) in the left frontoparietal sulci, rather than intracranial hemorrhage. The patient received tirofiban, dual antiplatelet therapy, and early rehabilitation. By discharge on day 7, he had achieved partial recovery (NIHSS score 9, mRS score 4).

Despite its extremely low incidence, the risk of anterior circulation cerebral embolism persists during transradial posterior circulation interventions. Gentle manipulation and emboli monitoring may mitigate this risk. Intraoperative neuromonitoring and rapid imaging are critical, and precise diagnosis and treatment can facilitate functional recovery.