Recurrent posterior circulation infarcts secondary to vertebral artery external compression treated with endovascular deconstruction

When multiple, recurrent infarcts occur in spite of maximal medical management, the level of suspicion for atypical vascular injury should be heightened. We present a case of a patient who presented with recurrent posterior circulation infarcts despite optimized medical management. On imaging, he was found to have external anatomical vertebral artery muscular and/or osseous compression leading to repetitive vascular injury and strokes. Recurrent intimal injury and vertebral artery to intracranial emboli despite anticoagulation and subsequent dual antiplatelet therapy necessitated definitive operative management. Surgical bypass, external surgical decompression, reconstructive endovascular, and deconstructive endovascular techniques were carefully considered. A deconstructive endovascular approach was chosen as the least morbid option. The use of endovascular plugs such as a microvascular plug provides a quick and effective means of achieving a therapeutic parent artery occlusion in lieu of traditional coil occlusion. Although reserved as a last resort, parent artery occlusion can be a viable option to treat recurrent strokes, particularly in a nondominant vertebral artery.