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Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported. Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns., Methods: Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up., Results: Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours., Conclusions: CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication., Methods: Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID., Results: Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups., Conclusion: The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.

A middle-aged patient presented with posterior circulation symptoms attributable to a large eccentric basilar trunk aneurysm. The planned treatment was flow diversion with loose coil packing which was successfully performed using a Pipeline Flex device deployed from the basilar to the left posterior cerebral artery. The complete procedure including live biplane fluoroscopy was digitally recorded. The patient had symptomatic improvement postoperatively and was discharged on day 1. The patient suffered a cardiac arrest on postoperative day 3 secondary to massive intraventricular and subarachnoid hemorrhage. An aneurysm rupture was suspected; however, postmortem examination showed an intact aneurysm sac. The hemorrhage was attributed to a small focal rent in the distal basilar artery next to an atheromatous plaque. The Pipeline device was visible through the rent. This is an autopsy report documenting an injury to the parent artery and not the aneurysm as a source of fatal delayed subarachnoid hemorrhage following flow diversion., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Traumatic clival fractures occur with less than 0.6% frequency and can be associated with significant neurovascular injuries. The most serious of these injuries is to the basilar artery in which the artery is dissected or is fully occluded, resulting in infarction of the brainstem and cerebellum. Among early reports of these injuries, postmortem autopsy showed entrapment, or incarceration, of the basilar artery at the clival fracture site. A literature search revealed 11 cases of entrapment of the basilar artery within a clival fracture., Case Description: This report describes a 59-year-old man after a motor vehicle crash with computed tomography showing a basilar artery herniation through a sphenoid sinus fracture. The patient subsequently developed brainstem and cerebellar infarcts., Conclusions: Basilar artery incarceration and herniation through the sphenoid sinus is rare. Such an injury portends a poor prognosis. We discuss the relevant clinical imaging and review the literature., (Published by Elsevier Inc.)

Injuries to blood vessels near the heart can quickly become life-threatening and include arterial injuries during central venous puncture, which can lead to hemorrhagic shock. We report 6 patients in whom injury to the subclavian artery and vein led to life-threatening complications. Central venous catheters are associated with a multitude of risks, such as venous thrombosis, air embolism, systemic or local infections, paresthesia, hemothorax, pneumothorax, and cervical hematoma, which are not always immediately discernible. The subclavian catheter is at a somewhat lower risk of catheter-associated sepsis and symptomatic venous thrombosis than approaches via the internal jugular and femoral veins. Indeed, access via the subclavian vein carries a substantial risk of pneumo- and hemothorax. Damage to the subclavian vein or artery can also occur during deliberate and inadvertent punctures and result in life-threatening complications. Therefore, careful consideration of the access route is required in relation to the patient and the clinical situation, to keep the incidence of complications as low as possible. For catheterization of the subclavian vein, puncture of the axillary vein in the infraclavicular fossa is a good alternative, because ultrasound imaging of the target vessel is easier than in the subclavian vein and the puncture can be performed much further from the lung.

Introduction: Endoscopic third ventriculostomy (ETV) is a simplified treatment relative to shunting for several types of hydrocephalus. The fatal complication of ETV is intraoperative hemorrhage due to arterial injury of the basilar artery, posterior cerebral arteries, and their perforators., Material and Methods: Here, we present a modified technique of ETV by using a transendoscopic pulse-waved microvascular Doppler probe and videoscope head to avoid vascular injury behind the tuber cinereum (TC). The microvascular Doppler probe can detect the basilar artery complex through the TC., Conclusion: Ventriculostomy with the probe head helps prevent vascular injury by informing the presence of invisible vessels under endoscopic view during perforation, and the method introduced here is certain to prove invaluable for enhancing the safety of ETV.

Transorbital penetrating injuries are rare and present with a heterogeneity of intracranial injury patterns that require individualized therapeutic procedures. In this report, we describe the case of a distal basilar artery laceration in a 16-month-old boy caused by accidental transorbital penetration with a pencil. Surgical removal of the pencil was performed, but hemostasis could only be achieved by clipping the impaired vessel. Adequate diagnostics and an individualized surgical strategy are necessary to deal with these life-threatening injuries., (Georg Thieme Verlag KG Stuttgart · New York.)

Atlanto-occipital dislocation (AOD) is a grave injury that is rarely survivable. Patients who do survive often have long-term sequelae resulting from the intracranial damage sustained during the traumatic event. The high impact needed to cause AOD is translated to the intracranial vessels, which can lead to vascular injury. Pseudoaneurysm is one of the possible outcomes of damage to the vessel wall. We present a case of basilar artery pseudoaneurysm diagnosed 5 months after a traumatic AOD who was treated with intracranial stent placement and coiling.

Object: Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era., Methods: A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up., Results: Thirteen patients (8 women and 5 men, mean age 44 years, range 30-73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V(4) segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up., Conclusions: Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.

An individual in their 30s presented with quadriplegia and coma 7 h after a 30-foot free-fall. Angiography confirmed left vertebral artery dissection causing vertebral artery occlusion (thrombolysis in myocardial infarction (TIMI) 0) and basilar artery thrombosis. Deployment of six self-expanding intracranial stents (right P1 to left V3) resulted in recanalization (TIMI 3). Postoperative MRI demonstrated a large brainstem infarction; the patient was 'locked-in'. In the following 6 months, the patient recovered to ambulation and independence. Aggressive recanalization for symptomatic vertebrobasilar dissection/occlusion may be considered. Despite major diffusion-weighted imaging brainstem lesions, recovery is possible.

Nail-gun injuries have become an increasingly prevalent source of penetrating intracranial trauma. Few cases of intracranial nail-gun injuries disturbing major cerebrovascular structures have been reported, and none entailing basilar artery involvement. We report here the case of a 51-year-old male with an intracranial nail-gun injury involving penetration of the distal basilar artery. Operative removal was accomplished under direct vision using a double concentric cranioorbital zygomatic osteotomy for a trans-Sylvian approach. We highlight the principles involved in removing foreign bodies penetrating critical neurovascular structures.

A 51-year-old gentleman with no significant past medical history presented with a WFNS grade 1 subarachnoid haemorrhage. Initial angiographic investigations revealed no cause, but repeat tests showed a small basilar perforator aneurysm. Following a failed attempt at endovascular treatment, a craniotomy and excision of the aneurysm was performed. Post-operatively the patient made a good recovery. This case highlights the importance of delayed repeat catheter angiography in selected patients with suspicious initial CT head results.

Objectives: A serious catastrophic complication of endoscopic third ventriculostomy (ETV) is basilar artery (BA) damage. Although the BA has been discussed as the cause of haemorrhage and even pseudoaneurysm, variations of the posterior cerebral artery proximal segment (P1) and its protrusion into the third ventricle floor have not been emphasised. A series of cases are reported in which the P1 segment was located at the stoma during an ETV and was at risk of perforation. Precautionary techniques for complication avoidance are described., Methods: A retrospective review was performed of all ETVs performed in adults at our institution between 2004 and 2008. Cases were identified in which the P1 segment was noted to herniate into the stoma at the time of third ventricular floor fenestration., Results: Among 65 cases reviewed, six were identified in which the P1 segment significantly herniated into an area of the stoma at the time of third ventricular floor fenestration. In no case was the P1 segment injured by the ETV procedure. Each of the six patients had opaque third ventricle floors. A 'cookie cut' technique was used in which the opaque third ventricle floor was abraded to reveal the underlying translucent membrane, offering an improved view of arteries in the basilar cisterns. In four of six patients, ETV resulted in clinical improvement., Conclusions: The posterior cerebral artery P1 segment is potentially at risk during ETV in adults as well as in children. Awareness and proper precautions may help reduce injuries to either the P1 or the basilar apex during an ETV.

A 76-year-old man presented with brain stem hemorrhage after burr-hole drainage for bilateral chronic subdural hematomas. Neuroimaging demonstrated resolution of the transtentorial herniation but also detected new brain stem hemorrhage, manifesting as gait disturbance. He recovered after conservative treatment. Asymmetrical and rapid decompression, which leads to vascular disruption and/or sudden increase in cerebral blood flow, was probably responsible for the secondary brain stem hemorrhage. Therefore, simultaneous and bilateral decompression with a slow rate of evacuation of massive bilateral chronic subdural hematomas is recommended to prevent serious complications such as secondary intracranial hematoma.

Traumatic subarachnoid hemorrhage after blunt head injury or neck trauma most often occurs due to intracranial or extracranial vertebral artery rupture. A literature review confirms that subarachnoid hemorrhage related to basilar artery disruption is a rare event. Strong associations have been made between basal subarachnoid hemorrhage and relatively minor blunt force injuries to the face, head, or neck. Moreover, the degree of hemorrhage may appear striking and disproportionate to the external and internal evidence of injury. We present a case of an assault-related basilar artery tear causing fatal subarachnoid hemorrhage, despite minimal external injury. This report provides an overview of potential mechanisms accounting for vertebrobasilar system rupture, with application to our case., (Crown Copyright 2009 Published by Elsevier Ltd.)

Aim: Cervical spine together with vestibular system,visual system and proprioceptive afferents plays an important role in mentaining balance. Spine damage causes distortions in transmitting informations to the brain,favoring vertigo., Material and Method: The authors point out the occurrence of positional vertigo on 23 patients (20 patients with cervical spondylosis and 3 patients with cervical spine injury) due to blood flow disturbance through vertebral artery., Results: The mechano-receptors located in intervertebral disks and cervical spine muscles are activated by column movement. Changes of blood flow in the vertebral and basilar arteries are showed up by cervical X-Rays, intracranial Doppler ultrasound or angio-MRI, an audiogram marking out the degree of hearing loss or tinnitus occurence. ENT complex treatment outcomes are analyzed and balneo-physio-therapy performed in order to improve vertigo and hearing loss., Conclusions: Stress beside muscle overload and cervical spine injures causes alteration in the ear blood-flow circulation that leads to hearing loss, vertigo and tinnitus. It emphasies the need for collaboration between balneologist and ENT specialist in solving balance and hearing disorders with cervicogenic cause.

The objective of the present study was to evaluate the correlation between sympathetic nerve activation and inflammatory response in the acute stage of subarachnoid hemorrhage (SAH) in a canine perforating model. SAH was induced by perforation of the basilar artery with the use of a microcatheter via the femoral artery in 20 mongrel dogs. Hemodynamic parameters and intracranial pressure were recorded, and blood sample for C3a, C5b-9, IL-6, IL-8 and noradrenaline kinetic determination were measured at 0, 5, 15, 30, 60, 120, and 180 min after SAH. Noradrenaline (pg/mL) increased abruptly from 104+/-59 to 2010+/-918 at 5 min after SAH. C3a and C5b-9 reached peak values at 15 min and IL-6 and IL-8 reached peak values at 30 min after SAH, respectively. The peak values of C3a and C5b-9 correlated positively with the peak value of noradrenaline (r=0.743 and r=0.753, respectively). The peak values of IL-6 and IL-8 also correlated positively with the peak values of noradrenaline (r=0.603 and r=0.681, respectively).These results suggest that a pronounced activation of the sympathetic nervous system and the inflammatory response occurs in acute stage of SAH. Significant association between the rate of spillover of norepinephrine to plasma and the plasma levels of inflammatory markers indicates that the two processes, sympathetic activation and immune response are quantitatively linked in early stage after SAH. The exact mechanisms underlying this phenomenon deserved further investigations.

Background: Sudden sensorineural deafness is a well-known symptom mostly of unknown etiology., Case Description: A case of sudden sensorineural deafness is reported to be caused by a small, remote, ipsilateral tentorial meningioma not compressing the vestibulocochlear nerve or auditory tract. Surgical resection of the meningioma immediately restored the patient's hearing., Conclusion: The authors hypothesize that the sudden sensorineural deafness resulted from a growing meningioma inducing a neurovascular compression of the vestibulocochlear nerve, the vertebral artery already being in close relationship with the vestibulocochlear nerve in the premorbid phase. Resection of the meningioma allows for an autodecompression of this vascular conflict resulting in hearing restoration.

A 77-year-old male pedestrian was hit by a car. On admission, he had disturbance of consciousness and left hemiplegia. Computed tomography (CT) indicated only left frontal subcutaneous hematoma and minor hemorrhage in the left frontal lobe, suggesting axonal injury. CT on hospital day 2 revealed a low density area in the right paramedian pons, but CT angiography showed no dissection or occlusion of the vertebrobasilar artery. The diagnosis was pontine infarction resulting from shearing force injury to the paramedian branch of the basilar artery. He was transferred to another hospital for rehabilitation without improvement of symptoms on hospital day 51. Paramedian pontine infarction tends to occur in patients with risk factors for arteriosclerosis, including hypertension, diabetes mellitus, hyperlipidemia, or smoking. The present elderly patient had hypertension and hyperlipidemia, so arteriosclerosis in the paramedian branch may have contributed to his susceptibility to such injury.

Vertebrobasilar junction entrapment due to a clivus fracture is a rare clinical observation. The present case report describes a 54-yr-old man who sustained a major craniofacial injury. The patient displayed a stuporous mental state (Glasgow Coma Scale [GCS]=8) and left hemiparesis (Grade 3). The initial computed tomography (CT) scan revealed a right subdural hemorrhage in the frontotemporal region, with a midline shift and longitudinal clival fracture. A decompressive craniectomy with removal of the hematoma was performed. Two days after surgery, a follow-up CT scan showed cerebellar and brain stem infarction, and a CT angiogram revealed occlusion of the left vertebral artery and entrapment of vertebrobasilar junction by the clival fracture. A decompressive suboccipital craniectomy was performed and the patient gradually recovered. This appears to be a rare case of traumatic vertebrobasilar junction entrapment due to a longitudinal clival fracture, including a cerebellar infarction caused by a left vertebral artery occlusion. A literature review is provided.

We performed a retrospective review of consecutive patients at our institution who underwent endoscopic third ventriculostomy (E3 V) or fenestration of intraventricular cysts using the Grotenhuis endoscopic perforator. The procedure was performed on 23 patients between 2001 and 2006, and included 20 E3Vs and three intraventricular cyst fenestrations. The Grotenhuis perforator was effective in accomplishing a fenestration with multiple attempts. When the floor of the third ventricle was translucent, the perforator was effective with the least amount of effort. The instrument was less effective and additional instruments were necessary in patients with arachnoid cysts or when the floor of the third ventricle was thick. The main advantage in using the Grotenhuis perforator was in displacing the floor of the third ventricle away from the basilar artery during perforation. No basilar artery injury or other serious complications occurred in patients who underwent E3 V or cyst fenestration using the Grotenhuis perforator.

A 28-year-old male car driver was reported to suddenly loose the control over his vehicle, to hit the right and middle crash barrier, and to be unconscious as the car came to a halt in a position at right angles to the road. The car was hit in its left side by an automobile with high velocity, and the 28-year-old driver died. Examination of the brain revealed a massive isolated basal subarachnoid hemorrhage and a complete tearing of the basilar artery. A macroscopically detectable aneurysm was not found. However, histological examination of the large arteries at the base of the brain showed (i) fibromuscular dysplasia (FMD) mostly involving the basilar artery (ii) with a ruptured micro-aneurysm in its upper third part. The observations of the eye witnesses that the driver initially lost control over his car were judged in favour of the accused to be due to that rupture of the micro-aneurysm, while complete transverse tearing of the basilar artery occurred during the car crash due to hyperextension and rotation of his neck. Intracranial FMD is a rare cause in the differential diagnosis of isolated basal subarachnoid hemorrhage. The medico-legal implications of this entity are described in the presented case.

Purpose: To report an uneventful sudden death because of a periorbital pellet injury., Method: Review of autopsy findings., Results: A 20-year-old hunter was shot accidentally during hunting. At autopsy, the body showed no significant injuries or deformity except for the pellet injuries and ecchymosis on the medial side of the left lower eyelid. Skull roentgenography located a pellet in the base of the cranium. Upon craniotomy, the cause of death was diagnosed as subarachnoidal haemorrhage due to incomplete basilar artery injury. The pellet entered through the medial cantus, passed through the inferior orbital fissure than the sphenooccipital junction and basilar artery and lodged in the pons., Conclusion: A-high index of suspicion is required in order to detect an intracranial extension in periorbital injuries.

Cerebellar haemorrhage is an unusual complication of supratentorial neurosurgery. Several causative pre-operative factors and medical risk factors may predispose patients to cerebellar haemorrhage, however its etiology remains still unclear. Only two case reports have previously described the occurrence of cerebellar haemorrhage after subdural haematoma evacuation by burr-hole trepanation. We present two patients with this rare postoperative complication of minor supratentorial neurosurgery and possible underlying pathophysiological mechanisms are discussed. Our two cases support the post- rather than per-operative pathogenetic hypothesis. Although the complication is associated with a significant morbidity and mortality, most cases follow a benign course.

Vascular complications can and do arise from transsphenoidal surgery and, when they occur, they have a high incidence of mortality and serious morbidity. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications.

Based on our experiences with medico-legal autopsies, we analyzed traumatic injury of the vertebrobasilar artery (VBA) in traffic accident victims. VBA rupture occurred in six cases with traumatic medullary lesions, but in none with cervical cord injury. A relatively small external force applied to the head or neck can induce isolated traumatic subarachnoid hemorrhage (SAH), which accounts for approximately 11% of fatal head injuries. We examined the relationship between site of impact and site of vascular injury in 16 cases of isolated traumatic SAH. The results showed that the vertebral artery (VA) on the side of impact tended to be longitudinally injured in victims experiencing an external force equivalent to that of a fist punch to the head or face. There was no clear relationship between the site of impact and the site of vascular injury in victims who had sustained an external force greater than that of a fist punch. However, our results suggest that an external force causing rotation of the head was likely to cause tearing of the artery. In cases in which an external force equivalent to that of a fist punch was applied to the head, a raised blood alcohol level was a significant risk factor for artery rupture. Furthermore, a difference in the diameters of the left and right VAs was a risk factor for artery rupture. To determine why the VA, the most frequent site of arterial dissection, is also frequently the site of injury, we histologically examined normal and dissected VBAs. We also discuss medico-legal issues of the causal relationship between external force applied and rupture or dissection of the VA.

Objective: This study looked at the effects of single and multiple small subarachnoid hemorrhage (SAH) caused by puncturing a small branch of the basilar artery in rats., Methods: Rats were subjected to single SAH (n = 21), multiple SAH (n = 21), sham operation (n = 21), or no procedures (control group, n = 7). SAH was induced in rats by transclival puncture of a small branch of the basilar artery. In the multiple-SAH hemorrhage groups, three small hemorrhages were produced in the same artery at three different times (initial and 24 and 48 h). In the single-SAH groups, one small hemorrhage was produced. Measurements of local cerebral blood flow (LCBF) were made at the initial SAH procedure and at three different time points. Seven animals from each general grouping were killed on Days 4, 10, and 14 (after LCBF was measured). Three different levels of the basilar artery were examined in each animal. Luminal area and arterial wall thickness were measured, and the findings were compared with control and corresponding sham group findings., Results: LCBF dropped dramatically (by 40%) immediately after SAH and reached levels near baseline within 15 minutes (n = 42) (P < 0.001). LCBF continued to drop after initial SAH and reached the lowest level on Day 10 (P < 0.001) or Day 14 (P < 0.05). Significant luminal narrowing (P < 0.01) and thickening of the arterial wall (P < 0.01) were observed in both groups., Conclusion: Single or multiple small SAHs produced by puncturing the basilar artery in the rat cause similar acute and chronic cerebral vasospasm.

Obstructive hydrocephalus remains a problem, and improvements in fiberoptic technology have promoted interest in neuroendoscopic ventriculostomy (NTV) as an alternative to standard cerebrospinal fluid shunts. The present study assessed 210 pediatric NTVs performed between 1994 and 2004 in patients aged 2 months to 10 years. Five children needed same-session ventriculoperitoneal shunting due to insufficient bypass of the obstruction. The other 205 procedures were technically successful, but 7 patients needed early-postoperative shunting and 10 required late shunting. During NTV, 86 (40.1%) of the patients developed arrhythmia. One patient arrested during balloon dilatation, but normal rhythm returned after deflation and epinephrine/atropine therapy, with no resultant morbidity. Twenty-six (10.2%) patients developed tachycardia (without hypertension) followed by bradycardia, and 6 children (2.8%) developed hypertension. In 1 case (0.5%), a branch of the basilar artery ruptured during fenestration and the hemorrhage was controlled after craniotomy. In 5 cases, mild venous bleeding was controlled by irrigation. The early complications included transient ocular divergence (n = 1), anisocoria (n = 2), and hyponatremia (n = 5). Five children were diagnosed with temporary diabetes insipidus in the late-postoperative period. The neuroendoscopic approach is considered safe for treating hydrocephalus in children, but complications can be severe or lethal and the anesthesiologist must respond accordingly.

A 46-year-old motorcyclist sustained severe cranio-facial fractures from a fall at 60 km/h. He gradually developed a left hemiparesis and diplopia but retained a GCS of 15. CT head scan revealed a longitudinal clivus fracture. MRA of intracranial vessels identified a trapped basilar artery. The patient made an excellent recovery with residual left abducens palsy on follow-up at 10 weeks. Such recovery with minimal residual deficit in the context of this injury has not previously been reported. Reported cases to date are reviewed and causative mechanisms discussed.

Ruptures of arteries of the vertebrobasilary system are relatively frequent in medicolegal practice, and their origin may be both natural and violent. Tears that affects the whole thickness of the basilar artery cause subarachnoid hemorrhage (SAH), with an often rapid fatal outcome. 1-3 However, in some situations, arterial tears may be incomplete, involving the intima or both the intima and the media, but with preserved adventitia. 1, 4 Although such incomplete tears are not the source of immediate subarachnoid bleeding, their presence may be important from both a medicolegal and a clinical point of view. The aim of this article is to point out the significance of incomplete tears of basilar artery as a possible diagnostic sign of traumatic origin of SAH as well as a certain mechanism of injury, which involves forcible hyperextension and rotational movements of the head. The authors also describe their method of performing longitudinal section of the basilar artery, both at autopsy and for histologic examination, which is convenient for identifying multiple transversal incomplete tears of this blood vessel. The article is based on the analysis of three cases from the autopsy material of the Institute of Forensic Medicine in Belgrade.

Basilar artery injury has been known as a potential lethal complication of endoscopic third ventriculostomy. In order to avoid this complication, endoscopic reverse third ventriculostomy via a trans-cisterna-magna route was studied. A cadaveric study was performed for navigation of a flexible endoscope through the cisterna magna. Three fresh, unfixed cadavers were used for this endoscopic navigation. In the prone position, a small vertical paramedian skin incision is made at the mid-portion of the posterior neck. An 11-mm threaded plastic tube is inserted towards the posterior arch of the atlas. After a partial hemilaminectomy of the atlas, a flexible endoscope is introduced into the cisterna magna and is navigated cephalad along the vertebrobasilar artery to the inferior aspect of the floor of the third ventricle. Through the working channel of a fiberscope, third ventriculostomy is performed in a reverse direction. Additional detailed anatomy was studied in fixed cadaveric head specimens with a rigid rod-lens endoscope for anatomic orientation. A novel technique of a trans-cisterna-magna reverse third ventriculostomy was studied in cadaveric specimens. This technique may avoid basilar artery injury which occurs occasionally during conventional third ventriculostomy.

We reviewed 29 patients with vertebrobasilar dissections (VBD) to investigate the correlation between minor trauma and VBD and the clinical features of this trauma-related condition. Mean age was 43 years, with a male predominance (male/female ratio was 25/4). Seventeen patients presented with subarachnoid hemorrhage (SAH), and 12 with ischemic symptoms. Two patients presenting with ischemia had extracranial VBD (V3 segment). Angiographically, aneurysmal dilatation was observed in most SAH patients (13 patients) in contrast to narrowing or occlusion in most ischemic patients (10 patients). Among the 12 SAH patients treated with coil embolization or conservatively, five died, whereas all ischemic patients recovered well with anticoagulation and/or antiplatelet therapy. Seven patients had received minor or trivial head/cervical trauma, due to whiplash injury, minor fall, or during exercise, which were identified to precede with the lapse of some time (a few minutes or days) the onset of symptoms. All of these patients presented with ischemic symptoms, and they were younger than the other ischemic or SAH patients. The site of vertebral artery dissection was intracranial in four cases, extracranial in one case, and combined in two cases at the level of the V3 segment and the origin of the posterior inferior cerebellar artery. However, no SAH occurred. These clinicopathological findings, i.e. ischemia and angiographic narrowing/occlusion, suggest that dissections were subintimal. Therefore, it is believed that this minor or trivial trauma may primarily cause subintimal dissection with luminal compromise, leading to ischemic symptoms, rather than subadventitial or transmural dissection with aneurysmal dilatation, leading to SAH. This lesion may also occur in younger patients with a favorable outcome. Careful note should be made of patient for the early recognition of this disorder.

Objective and Importance: Third ventriculostomy for the management of noncommunicating hydrocephalus is a commonly performed procedure with a 5% complication rate. One of the known complications is basilar artery injury., Clinical Presentation: We report a case of basilar artery injury, intraventricular hemorrhage, and false aneurysm formation in a 30-month-old boy after third ventricle floor fenestration., Intervention: The false aneurysm was managed with endovascular trapping by use of Guglielmi detachable coils without morbidity., Conclusion: Endovascular therapy can be used successfully to manage vascular injury after third ventriculostomy.

A 56-year-old man presented with a rare traumatic basilar artery occlusion caused by a fracture of the clivus. He fell from the height of 2 meters and immediately fell into a coma. Head computed tomography (CT) revealed an open depressed fracture, an acute epidural hematoma 1 cm thick in the left middle frontal fossa, and a longitudinal fracture of the clivus. Emergency removal of the hematoma was performed with cranioplasty. Head CT 8 hours 50 minutes after injury showed infarctions in the brain stem, cerebellum, and occipital lobes. Cerebral angiography revealed occlusion of the basilar artery in the middle part of the clivus. The patient died after 3 days. Autopsy revealed that the basilar artery was trapped in the clivus fracture site. Vertebrobasilar artery occlusion due to trapping in a clivus fracture has a very poor prognosis. Diagnosis is difficult and generally only confirmed at autopsy. Cerebral angiography is recommended in a patient in a deep coma without massive brain contusion at the early stage of head injury to identify the possibility of vertebrobasilar artery occlusion in a clivus fracture.

Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.

Two cases of traumatic rupture of the basilar artery are reported. In the first case, severe basal subarachnoid hemorrhage (SAH) due to a complete transverse tear of the basilar artery was observed in a 53-year-old restrained male driver who was involved in a head-on collision while intoxicated and drowsy. He lost consciousness shortly after the accident and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 50 minutes after the accident. The ethanol concentration in his blood and urine was 0.35 and 0.55 mg/ml, respectively. In the second case, SAH due to a similar tear of the basilar artery was observed in a 47-year-old man who received several fist blows to the face while intoxicated. He suddenly lost consciousness after the final blow and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 6 hours after the event. In these cases, the mechanism of the traumatic rupture of the basilar artery is thought to be overstretching due to hyperextension of the head, and intoxication, drowsiness, or both may have interfered with the decedents' ability to protect themselves; thus, the hyperextension of the head may have been rather forceful.

Dissection of a cerebral blood vessel is a rare complication of acute neurotrauma with a high incidence of morbidity and mortality. We report on a case of a pediatric patient with severe neurological symptoms in whom angiography showed evidence of a basilar artery dissection. The patient was heparinized and recovered uneventfully.

Study Design: Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993., Objectives: To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized., Summary of Background Data: Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear., Methods: A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized., Results: The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted., Conclusions: The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Basilar artery (BA) injury has been reported in a number of cases as a major complication of third ventriculostomy for hydrocephalus. This report describes the deployment of a pulsed-wave microvascular Doppler probe through the endoscope to locate the BA complex and subsequently to select a safe zone for perforation of the third ventricular floor. This procedure is quick and easily learned, and it is hoped that it can decrease the risk of vascular injury during third ventriculostomy.

Basilar artery occlusion (BAO) causing brainstem infarction occurred in a 7-year-old boy without any basic disorders. A diagnosis of BAO due to basilar artery dissection (BAD) was suspected at angiography, and this was confirmed by gadolinium-enhanced magnetic resonance imaging (MRI). These investigations clearly showed all the typical diagnostic signs such as a pseudolumen, double lumen and intimal flap, and a pseudolumen in resolution. The spontaneous healing of the dissection was clearly demonstrated during 10 months of follow-up. We stress that BAD can occur in young children and that combined diagnosis with gadolinium-enhanced MRI and angiography is conclusive for diagnosis of dissecting aneurysms. Wider use of these combined diagnostic methods will allow the detection of less severe basilar artery dissection, thus extending the spectrum of presentation and prognosis.