Search

Glossopharyngeal neuralgia due to vertebrobasilar dolichoectasia is a rare form of neuropathic pain, and presents diagnostic and therapeutic challenges. Clinical presentation: A 67-yearold man presented with severe burning pain in the left oral cavity, with no explanatory findings during dental and ear, nose, and throat evaluations. Temporomandibular joint examination revealed tenderness, and panoramic radiographs showed a noncontributory periapical radiolucency. Magnetic resonance imaging/magnetic resonance angiography revealed abnormally tortuous vertebral arteries compressing the glossopharyngeal nerves and the brainstem. Topical lidocaine reduced pain, confirming glossopharyngeal neuralgia. Carbamazepine was initially ineffective, but at 200 mg pain reduced from 90 to 20 on the visual analog scale. The patient requested and underwent microvascular decompression surgery, which eliminated his pain. Conclusion: When the vertebral artery compresses the glossopharyngeal nerve, the pain is more intense, attributed to its thicker vascular structure. Local anesthetic testing aids in identifying glossopharyngeal neuralgia. Dental practitioners must be skilled in diagnostics and possess anatomical knowledge for accurate evaluation and referral of throat and ear pain. [ABSTRACT FROM AUTHOR]

Purpose: To describe a case of atypical course of V3 segment of the right vertebral artery (VA) that runs through the hypoglossal canal. Methods: A 60-year-old female was qualified as clinical control group to participate in a clinical trial and two imaging methods in High Field Magnetic Resonance Imaging (1.5T): 3D FFE TOF and 3D T1 MPRAGE were performed. Results: In this case, the right VA enters the skull abnormally, through the hypoglossal canal. Research has shown that it is presumably a variant of persistent primitive hypoglossal artery (PPHA) or a partial persistence of the PPHA incorporated into the VA. Previous MRI images did not reveal any abnormalities in the structure in the vasculature of the brain, as well. Conclusion: Proper recognition and analysis of vascular variations are critical to avoid iatrogenic complications or to plan surgery of head or neck regions. Secondly, such anatomic variation may predispose a patient to ischemic attacks due to insufficient blood flow or aneurysms due to a weakened wall or stenosis of the VA. [ABSTRACT FROM AUTHOR]

The study investigates the interaction between vertebral artery stenosis and pulsatile blood flow, with a focus on the mechanical properties and internal dynamics of blood flow. First, an asymmetrical stenosis mathematical model was established to reveal the relationship between the resistance ratio and shear stress ratio and their dependence on stenosis height and length. Next, various stenosis models were constructed using medical imaging data and analyzed through computational fluid dynamics (CFD) and fluid–structure interaction (FSI) methods. Finally, hemodynamic parameters, such as blood flow velocity and time-averaged wall shear stress (TAWSS), along with solid mechanics indicators, including total deformation and von Mises stress, were evaluated. The results indicate that changes in stenosis length and height significantly affect the resistance ratio and shear stress. Whole-segment stenosis in the vertebral artery may lead to thrombosis and intimal damage. In contrast, stenosis at the ostium of the vertebral artery increases the risk of platelet deposition on the vessel wall, potentially triggering atherosclerosis. This could ultimately lead to insufficient blood flow to the brain due to impaired vertebral artery circulation. FSI simulations revealed that elastic vessel walls are more sensitive to high-velocity flows, especially in stenotic and downstream regions. These findings provide critical insights into the effects of stenosis on blood flow and are crucial for developing effective clinical intervention strategies. [ABSTRACT FROM AUTHOR]

Background: The relative risk of ischemic stroke (IS) in head and neck cancer (HNC) patients developing carotid artery stenosis (CAS) or vertebral artery stenosis (VAS) after radiation therapy (RT) remains uncertain due to limited studies, complicating vascular follow-ups and preventive strategies. Methods: We included HNC patients who received RT between 2010 and 2023. The patients were divided into nasopharyngeal carcinoma (NPC) and non-NPC groups. The primary outcome was the occurrence of IS after RT, and the secondary outcomes included the development of > 50% CAS or > 50% VAS after RT. Results: Of the 1,423 HNC patients, there were 19% of patients developed > 50% CAS, 6.8% of patients developed > 50% VAS, and 2.3% of patients developed IS. In patients with HNC, > 50% CAS (adjusted hazard ratio [HR] = 3.21, 95% confidence interval [CI] = 1.53–6.71), and > 50% VAS (adjusted HR = 2.89, 95% CI = 1.28–6.53) were both the independent predictors of IS. In the patients with NPC, > 50% CAS was an independent predictor of anterior circulation IS (adjusted HR = 4.39, 95% CI = 1.17–16.47). By contrast, > 50% VAS emerged as a predictor of posterior circulation IS in both the NPC (adjusted HR = 15.02, 95% CI = 3.76–60.06) and non-NPC groups (adjusted HR = 13.59, 95% CI = 2.21–83.46). Conclusion: HNC patients with > 50% CAS or > 50% VAS after RT had an increased risk of IS within their corresponding vascular territory. CAS could be an important predictor of IS in NPC patients, whereas VAS might also be a significant predictor of IS in both NPC and non-NPC patients. Evaluation both the carotid and vertebral arteries after RT might be necessary. Trial registration: ClinicalTrials.gov identifier No.: NCT06111430. [ABSTRACT FROM AUTHOR]

Flow diverter (FD) deployment combined with coil therapy is effective and considered superior to FD deployment alone for treating large, complex anterior circulation aneurysms. However, the optimal strategy for coil usage in posterior circulation aneurysms, particularly intracranial vertebral artery dissection aneurysms (IVADAs), remains unclear. This study used patient-specific aneurysm models and finite element analysis to determine the ideal packing density (PD) of coils following FD placement in IVADAs. We prospectively analyzed 22 patients with 24 aneurysms, all treated with FD at our hospital. Hemodynamic parameters were analyzed before treatment, after FD alone, and at three different coiling rates (5%, 15%, and 25%) using software simulation. All 22 patients underwent FD procedures to treat IVADAs. FD deployment and additional coil use both reduced the inflow rate at the aneurysm neck, the inflow concentration index, and the mean velocity in the aneurysm. However, compared with FD treatment alone, coils provided a smaller reduction in these parameters. No significant difference in the reduction ratio was observed when the coiling PD increased from 5 to 15% and then to 25%. Further coil addition beyond a 5% PD produced no notable hemodynamic benefits. Adjunct coiling improves the post-FD hemodynamic environment of treated IVADAs. However, dense packing is unnecessary because the intra-aneurysmal hemodynamics tend to stabilize once the PD reaches approximately 5%. [ABSTRACT FROM AUTHOR]

Bow Hunter syndrome (BHS) is a rare disorder characterized by mechanical occlusion of the vertebral artery (VA) during neck rotation, resulting in symptomatic, transient, and positional vertebrobasilar insufficiency. We describe a case of a 76-year-old female who presented with dizziness and right ear tinnitus triggered by right head rotation. Her symptoms would immediately resolve upon returning her head to the neutral position. CT angiogram showed 80% stenosis of the left subclavian artery origin, 50%–70% stenosis of the proximal right internal carotid artery (ICA), and near occlusive stenoses of the origins of the bilateral VAs. After failing conservative management, the patient was treated with left subclavian artery stenting, followed by a right carotid endarterectomy (CEA) 6 weeks later. Follow-up at 1 month showed resolution of paroxysmal symptoms and no neurological sequelae. To our knowledge, there have not yet been reported cases of patients with concurrent BHS, subclavian artery stenosis, and carotid artery stenosis. We suggest that global revascularization via subclavian artery stenting and CEA may be considered as treatment for patients with BHS complicated by other cerebrovascular disease secondary to stenoses of the ICA and subclavian artery. This approach obviates the need for more complex surgery or endovascular intervention of the VA. [ABSTRACT FROM AUTHOR]

Background: To evaluate the feasibility, success rate, and safety of endovascular revascularization of patients with vertebral artery stump syndrome (VASS). Methods: This single-center retrospective study analyzed clinical and imaging data from consecutive patients with VASS who underwent endovascular recanalization from January 2020 until June 2023. Results: Our study enrolled 30 patients [mean age 69 (range 51-84) years; 26 men]. The rate of successful technical revascularization was 96.7% (n = 29), and the rate of complications was 3.3% (n = 1). At the 6-month follow-up, the patients with successful endovascular revascularization of VASS did not have any neurological symptoms, and computed tomography angiography showed 3/29 (10.3%) re-occlusions and 4/29 (13.8%) restenosis of the stent, which was confirmed by digital subtraction angiography. Conclusions: Endovascular recanalization in patients with VASS is feasible in selected patients and has a high procedural success rate and low rate of complications. A large, multicenter, randomized study is warranted to confirm these findings. [ABSTRACT FROM AUTHOR]

The article discusses a rare case of micro guidewire (GW) fracture during endovascular treatment for basilar artery stenosis in a 59-year-old female. Despite failed attempts to retrieve the GW endovascularly, a far-lateral craniotomy and V3 arteriotomy were performed successfully. The patient had no complications in follow-up, highlighting the importance of microsurgery as a salvage treatment in such rare events. The article also touches upon other reported cases of GW complications during neurointervention, emphasizing the need for careful consideration and appropriate techniques in such procedures. [Extracted from the article]

The article in the Journal of Neurological Surgery details the anatomical step-by-step dissection of complex skull base approaches, focusing on the transmastoid high cervical approach to the jugular foramen and C1-C2 junction. The study utilized cadaveric specimens to provide a detailed description of the surgical techniques involved in accessing these challenging areas. The transmastoid high cervical approach offers a direct corridor to the jugular foramen, craniocervical junction, and C1-C2 junction, making it a valuable tool for skull-base surgeons. [Extracted from the article]

The article "Modified Far Lateral Approach to the Ventral Foramen Magnum and Craniocervical Junction: Surgical Results in 35 Cases" published in the Journal of Neurological Surgery. Part B. Skull Base discusses a surgical approach for resection of lesions involving the craniocervical junction (CCJ). The study included 35 cases, with the most observed tumors being foramen magnum and jugular tubercle meningiomas. The modified far lateral approach resulted in a 90.9% gross total resection rate with an overall complication rate of 25%. The authors concluded that the modified approach showed excellent surgical outcomes in their series. [Extracted from the article]

The article "Surgical Anatomy of the Anterolateral Approach: Step-by-Step Dissections" published in the Journal of Neurological Surgery. Part B. Skull Base discusses the challenges of accessing the jugular foramen due to its complex relationship with neurovascular structures. The anterolateral approach described by Bernard George provides access to this area with multiple exposures and extensions, allowing for surgical treatment of various tumors. The study conducted anatomical dissections on cadaveric specimens to provide a detailed guide for this surgical approach, emphasizing the importance of understanding the complex anatomy involved. [Extracted from the article]

This article from the Journal of Neurological Surgery explores the feasibility and safety of preoperative endovascular embolization for extra-axial tumors in the posterior fossa. The study analyzed 41 patients who underwent this procedure, focusing on factors such as lesion location, arterial feeders, and devascularization grades. The results suggest that preoperative embolization may aid in achieving complete tumor resection without significant complications, although further studies are needed to assess its impact on surrounding brain tissue. [Extracted from the article]

The article discusses the various surgical techniques used to treat C1-C2 instability, focusing on the posterior approach. The study conducted at a tertiary healthcare center in Eastern India reviewed 23 complex cases of C1-C2 instability, with positive outcomes in terms of improved postoperative imaging and patient improvement. The authors conclude that posterior C1-C2 fixation is a safe and effective method for addressing C1-C2 instability, even in cases of vertebral artery abnormality. The study highlights the importance of C1-C2 fixation in treating conditions such as Chiari malformation and failed foramen magnum decompression. [Extracted from the article]

Hemifacial spasm secondary to a dolichoectatic vertebral artery is a rare but debilitating condition. Macrovascular displacement of the vessel away from the nerve using a Teflon sling is an effective but not always a feasible method. In this video, we demonstrate simple microvascular decompression of the root entry zone to be a safe and effective technique for treating hemifacial spasm, despite residual compression of the nerve complex more distally in the cisternal segment.By Adel Azghadi; Marte Close-van Keulen and Sepideh Amin-HanjaniReported by Author; Author; Author [Extracted from the article]

In this video, we presented the resection of a large craniovertebral junction chordoma using an extreme posterolateral approach. This approach is a valuable option for midline lesions with lateral condyle extension and intradural extension offering the possibility of a craniovertebral junction fixation during the same stage. Transposition of the vertebral artery provides access to the lateral mass of C1. The anteriorly located part of the tumor on the opposite side was removed with endoscopic assistance.By Thibault Passeri and Sébastien FroelichReported by Author; Author [Extracted from the article]

In this patient with severe and frequent fainting spells, the posterior circulation was found to be fed by collaterals. A bypass from the external carotid artery to the V3 segment of the vertebral artery was performed.By Jessica Eaton; Varadaraya Shenoy; Emma Celano and Laligam SekharReported by Author; Author; Author; Author [Extracted from the article]

The authors present a case of 68-year-old male with an incidental right PICA aneurysm diagnosed during the workup of left-sided tinnitus. Neurological examination was unremarkable. Computed tomography angiogram and digital subtraction angiography depicted a right complex lateral medullary segment PICA aneurysm. He underwent a right far lateral approach for PICA to vertebral artery in situ re-implantation bypass with clipping of the PICA takeoff. The patient tolerated the procedure well and he was discharged home.By Hussam Abou-Al-Shaar; Arka N. Mallela and Georgios A. ZenonosReported by Author; Author; Author [Extracted from the article]

A 46-year-old male presenting with dizziness and presyncope upon right head turn. Neurological examination was unremarkable. Computed tomography angiogram and digital subtraction angiography with right head flexion depicted severe right V2 segment vertebral artery stenosis secondary to facet hypertrophy that is relieved in neutral position. He underwent a right posterior transcervical approach for decompression of the vertebral artery in the transverse foramen at C2 and C3. The patient tolerated the procedure and his symptoms resolved.By Hussam Abou-Al-Shaar; Arka N. Mallela and Paul A. GardnerReported by Author; Author; Author [Extracted from the article]

The article in the Journal of Neurological Surgery. Part B. Skull Base discusses a rare case of a persistent primitive artery, known as the jugular artery, that forms a unique carotid-basilar anastomosis. The artery originates from the internal carotid artery, passes through the jugular foramen into the posterior cranial fossa, and merges with the basilar artery. The authors review the literature on persistent fetal anastomoses and suggest that this particular variant constitutes a new type of carotid-basilar anastomosis. Further research and reports are needed to confirm the morphogenesis and clinical implications of this rare vascular anomaly. [Extracted from the article]

The article discusses operative approaches to C2 Schwannomas, rare tumors in the upper cervical spine region. The study compares the classic posterior approach with the lateral-axial approach in 12 cases from 2010 to 2023. Results show that the lateral-axial approach may be a viable alternative, offering benefits such as preserving muscles, reducing operating time, and maintaining radical resection of the tumor. The study concludes that the lateral-axial approach shows promise in treating C2 Schwannomas effectively. [Extracted from the article]

Background Instrumentation of C2 vertebra is considered the most difficult for young neurosurgeons and trainees due to its complex anatomical structures, variety of surgical approaches and techniques, and proximity to important neurovascular structures. Key points from a surgical perspective for midline posterior approach is described in the era of neuroradiological advancements. Method Computed tomography angiographies (CTAs) of a total of 92 patients were evaluated with special attention to the key findings for insertion of screws for craniovertebral junction (CVJ) fixations. All these patients were operated though midline posterior approach in past 4 years. Results CTAs included various CVJ disorders, which included traumatic (n = 14), congenital (n = 55), and rheumatoid arthritis (n = 2) patients. Established landmarks for screw insertion sites do not prove safe for congenital anomalous CVJ conditions. Instead of highlighting screw insertion entry points, part of the corridor, which is relevant, should be stressed up on. Conclusion Midpoint of portion of bone segment medial to vertebral artery foramen should be the focus, which is important for pars interarticularis (and transarticular) and pedicle screws. A laminar screw should cross the midpoint of the lamina on each side. [ABSTRACT FROM AUTHOR]

Purpose: Stroke is among the leading causes of mortality and morbidity worldwide. The coexistence of bilateral carotid and vertebral artery (VA) occlusion and/or stenosis is in the very rare entity group in the literature. Here, we present a case with bilateral carotid artery occlusion and bilateral VA stenosis, who presented with an atypical clinical presentation and underwent bilateral vertebral percutaneous transluminal angioplasty (PTA) and stenting in the same session. Case Report: A 67 year old male patient was brought to the emergency department with complaints of inability to speak and weakness in both legs for 1 day. There were bilateral infarct areas in the anterior cerebral artery region and an additional infarct area in the left middle cerebral artery region. First, the right VA stenosis level was crossed using a 0.14 guidewire. After PTA, balloon-expandable stenting was performed with a 3.0×12 mm NC (non-compliant) balloon, and nearly complete recanalization was observed. Therefore, it was decided to perform an intervention on the left VA in the same session. Conclusion: As in this example case, in cases where cerebral perfusion is severely impaired, medical treatment after recanalization may be one of the best treatment options. Clinical Impact: The carotid arteries are the main arteries supplying the anterior circulation, and the vertebral arteries supply blood to the posterior circulation. However, in cases where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system. However, in cases such as this, where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system and may be responsible for anterior circulation strokes. The situation becomes more severe if both vertebral artery critical stenosis is added. Synchronous carotid and vertebral artery revascularization is not recommended in the guidelines for patients with combined carotid and vertebral artery disease. In patients with four-vessel occlusion/stenosis, as in this particular case, the intervention method and priorities are unclear. We achieved a favorable clinical outcome with simultaneous bilateral vertebral artery angioplasty and stenting, a hazardous method that can be a guide as an approach option in similar cases. [ABSTRACT FROM AUTHOR]

Background: Stroke is a global health concern, causing blood supply interruption to the brain. Vertebrobasilar stenosis (VBS) is the main concern, causing stroke or ischemic attacks. Treatment includes antithrombotic therapy and lifestyle modifications, but invasive intervention like endovascular angioplasty is needed in indicated patients. This study aims to investigate the short-term outcome of endovascular stenting, especially, drug-eluting stents (DES) for symptomatic vertebrobasilar stenosis. In this prospective cohort study, we selected patients with ischemic events, including transient ischemic attack (TIA) or non-disabling stroke, diagnosed by CT or MRI brain, MRA, and over 70% diameter stenosis of the basilar or vertebral artery suggested by angiography. Patients with previous stent at the target lesion, acute stroke, heavily calcified lesion, complete artery occlusion, massive infarction with marked neurological deficit, intracranial hemorrhage, intracranial brain tumors, contraindicated to antithrombotic and/or anticoagulant, pregnant women, and patients susceptible to follow-up loss were excluded. Results: This study involved 17 patients evaluated for ischemic events in the vertebrobasilar system, with a mean age of 58.47 ± 9.41 years. The most prevalent comorbidity was a previous transient ischemic attack (TIA) in 15 patients (88.2%), followed by hypertension in 12 patients (70.6%), diabetes and hyperlipidemia in 10 patients each (58.8% for both). Ischemic heart disease was present in 6 patients (35.3%), and smoking was reported by 5 patients (29.4%). The predominant stenosis location was intracranial in 11 patients (64.7%), with extracranial being the second most prevalent site in 6 patients (35.3%). The most prevalent kind of stenosis observed was atherosclerosis, affecting 11 patients (64.7%), followed by dissection in 6 patients (35.2%). The peri-procedural outcomes were good in 15 patients (88.2%) and bad in 2 patients (11.8%). The modified Rankin score (MRS) score was significantly decreased after 5-month follow-up than pre-operative. There was no statistically significant difference between extracranial and intracranial stenosis regarding the final outcome, residual stenosis, or peri-procedural complications. Conclusions: Our findings emphasize the potential advantages of stenting for carefully chosen individuals with symptomatic vertebrobasilar stenosis and simple lesion morphologies (Mori types A and B). However, further research is needed for patient selection and therapy optimization. [ABSTRACT FROM AUTHOR]

Background: Cerebral intra-arterial chemotherapy (CIAC) has been demonstrated to achieve tumoricidal concentrations in cerebral tumour cells that are otherwise unachievable due to the presence of the blood–brain barrier. In this study, we sought to analyze the safety of CIAC in a cohort of patients treated at the Centre intégré universitaire de santé et de services sociaux de l'Estrie—Centre hospitalier universitaire de Sherbrooke (CIUSSS-CHUS). Methods: Treatments consisted of monthly CIAC. A neurological examination and neuroimaging study (MRI) were performed before every treatment. The files of patients enrolled in our CIAC programme were reviewed. Adverse events were analyzed and categorized. Results: Overall, 2991 CIAC procedures were performed in 642 patients. Pathologies were as follows: malignant gliomas (68.7%), cerebral metastasis (17.6%), and cerebral lymphomas (13.7%). Perfusion vessels were as follows: 80% internal carotid artery and 20% vertebral artery. The chemotherapeutic agents used were carboplatin (86.4%), methotrexate (28.5%), melphalan (28.6%), and liposomal doxorubicin (2.8%). Osmotic blood–brain barrier disruption (BBBD) was induced in 30.5% of treatments. Symptomatic vascular adverse events occurred during 27 procedures (0.9%) in 26 patients (4%). Namely, 23 strokes, one carotid artery occlusion (responsible for one of the strokes), and two intratumoral and one subdural hemorrhage. The absolute risk of stroke was 1.3% and 0.5% for CIAC with or without BBBD, respectively. The use of the vertebral artery significantly increased the risk of stroke. Drug infusion-related seizures occurred in 2.5% of patients; 83.8% were associated with methotrexate and 16.2% with carboplatin. Conclusions: CIAC is a safe procedure with a 0.9% overall rate of symptomatic complications (stroke, carotid occlusion, subdural hemorrhage or intratumoral bleeding—n = 27/2991) on a treatment basis, mainly consisting of strokes (85%, n = 23), with a modified NIH Stroke Scale score of 4.1 ± 3.3. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to classify medullary bridging vein-draining dural arteriovenous fistulas (MBV-DAVFs) located around the foramen magnum (FM) according to their location and characterize their angioarchitecture and treatment outcomes. Methods: Patients with MBV-DAVFs diagnosed between January 2013 and October 2022 were included. MBV-DAVFs were classified into four groups. Jugular vein-bridging vein (JV-BV) DAVF: located in proximity to jugular fossa, Anterior condylar vein (ACV)-BV DAVF: proximity to anterior condylar canal, Marginal sinus (MS)-BV DAVF: lateral surface of FM and Suboccipital cavernous sinus (SCS)-BV DAVF: proximity to dural penetration of vertebral artery. Results: Twenty patients were included, three JV-BV, four ACV-BV, three MS-BV and ten SCS-BV DAVFs, respectively. All groups showed male predominance. There were significant differences in main feeders between JV (jugular branch of ascending pharyngeal artery) and SCS group (C1 dural branch). Pial feeders from anterior spinal artery (ASA) or lateral spinal artery (LSA) were visualized in four SCS and one MS group. Drainage pattern did not differ between groups. Transarterial embolization (TAE) was performed in three, two, one and two cases and complete obliteration was obtained in 100%, 50%, 100% and 0% in JV, ACS, MS and SCS group, respectively. Successful interventions without major complications were finally obtained in 100%, 75%, 100%, and 40% in JV, ACS, MS and SCS group, respectively. Conclusion: JV-BV DAVFs were successfully treated using TAE alone. SCS-BV DAVFs were mainly fed by small C1 dural branches of vertebral artery often with pial feeders from ASA or LSA, and difficultly treated by TAE alone. [ABSTRACT FROM AUTHOR]

The study analyzed images of patients with acute aortic dissection type A (AADA) to assess sex differences in aortic diameters. Women were found to have smaller aortic diameters at the time of dissection compared to men, with less aortic elongation. However, when indexed for patient height, the sex differences disappeared. Only half of the patients had aortic segments larger than 5 cm, indicating that not all would have met the current threshold for prophylactic surgery. [Extracted from the article]

Background: Multi-slice spiral computed tomography (CT) angiography (MSCTA) has become the primary non-invasive image technique for evaluating cephalic and cervical vascular anatomy, especially vascular variant such as persistent carotid-basilar anastomosis. Persistent proatlantal intersegmental artery (PPIA) is an example of a rare persistent carotid-basilar anastomosis that deserves to be featured through this imaging technic. Purpose: The aim of this study is to explore the imaging characteristics of the PPIA using MSCTA and to assess its clinical significance. Furthermore, the study seeks to propose a novel classification system predicated on the posterior circulation blood supply. Materials and methods: This retrospective analysis evaluated the imaging and clinical data of 11 patients diagnosed with a PPIA using MSCTA. Results: The incidence of the PPIA was found to be 0.01%. Classification based on the origin of the PPIA identified two cases (18.2%) as type I and nine cases (81.8%) as type II. This study introduced a novel classification system for PPIA, which is based on the posterior circulation blood supply, encompassing the persistent artery, vertebral artery, and posterior communicating artery. Among the 11 patients with PPIA, there were 11 instances of ipsilateral vertebral artery agenesis, three cases of contralateral vertebral artery hypoplasia, one case of contralateral vertebral artery agenesis, two cases of persistent artery hypoplasia, and two cases of basilar artery hypoplasia. Furthermore, the study identified two patients with aneurysms, one with cerebral infarction, and one with a Pulmonary Arteriovenous Fistula. Conclusion: The proposed classification system for PPIA enhances the understanding of posterior circulation blood supply, which is vital for pre-interventional and pre-surgical imaging assessments. In PPIA cases, the ipsilateral vertebral artery is consistently hypoplastic, and the PPIA predominantly serves the posterior fossa’s vascularization in about 75% of cases. [ABSTRACT FROM AUTHOR]

Background: Cervical fixation is a common treatment for conditions like vertebral fractures, osteosarcoma, osteomyelitis, arthritis, and congenital disorders. The study was designed to assess the occurrence of high-riding vertebral artery (HRVA), narrow C2 pedicles (NC2P) and ponticulus posticus (PP), which pose risks of injuring vertebral artery (VA) during screw placement in cervical fixation procedures. Methods: The study examined the prevalence of HRVA, NC2P and PP in 382 pedicle sides of the C2 vertebra using computed tomographic angiography scans. Specific measurements were taken, including the internal height (C2InH), and isthmus height (C2IsH) of C2, as well as NC2P width. Results: HRVA was identified by specific measurements: C2IsH of ≤ 5 mm and/or C2InHof ≤ 2 mm. NC2P was defined as NC2P width ≤ 4 mm. The reliability between observers and within the same observer, along with the consistency across different software, was assessed. At least one HRVA was found in 9.6% of patients and at least one NC2P in 13% of patients. Females demonstrated higher rates of HRVA and NC2Ps on the left side, with right-side figures at 10.5% and 11.7% for HRVA and NC2Ps respectively, and left side figures at 14.1% for both. Males exhibited a reserve pattern, with higher rates on the right side, marked by 10.3% HRVA and 15% NC2Ps, compared to 5.6% and 11.3% on the left. Furthermore, males showed a significantly higher occurrence of NC2Ps over HRVA on both sides. The presence of PP with NC2Ps detected in 44% of cases, and with HRVA in 16% of cases, a difference found to be statistically significant. Conclusions: The digital models incorporating HRVA, NC2P, and PP facilitated a comprehensive analysis of the VA pattern, assessment of the virtual screw trajectory line for VA pedicles, and the designation of specific regions during the procedure, ensuring increased safety planning instrumentation. [ABSTRACT FROM AUTHOR]

Purpose: To report an uncommon origin of the vertebral artery with embryological and clinical emphasis. Methods: A 55-year-old male with sepsis presented with altered level of consciousness. Head computed tomography (CT), and CT angiography of head and neck vessels (CTA) were performed in the stroke code setting. An analysis of his vertebral artery system on CTA with 3D modeling was performed to assess the embryology of a vertebral artery arising from the external carotid artery, Results: CTA revealed a dominant left vertebral arising from the left external carotid artery, the artery enters the transverse foramen at C2 and curves back behind the lateral mass of C1 entering the skull through the foramen magnum. The right vertebral artery was hypoplastic. Conclusion: Anatomical variants of the vertebral artery origin are asymptomatic, and they are the result of the persistence of anomalous anastomosis during early fetal life. Vertebral artery origin from the external carotid artery as seen in our case is explained by the persistence of the second cervical intersegmental artery. Awareness of this anatomical variant is essential to avoid misdiagnosis, and for surgical and endovascular treatment planning. [ABSTRACT FROM AUTHOR]

Background There are some cases where a radial artery (RA) graft is needed for a high-flow extracranial to intracranial (EC-IC) bypass as the external carotid artery (ECA) cannot be utilized as a donor artery. In this report, we describe two cases of extracranial vertebral artery (VA) to middle cerebral artery (MCA) high-flow bypass using an RA graft with an artificial vessel as an alternative bypass technique. Methods The patient was placed supine with a head rotation of 80 degrees. After frontotemporal craniotomy, another C -shaped skin incision was made at the retroauricular region and the V3 portion of the VA was exposed at the suboccipital triangle. Prior to attempting the high-flow bypass, the superficial temporal artery (STA) was anastomosed to the M4 portion of the MCA as an insurance bypass. The RA graft was anastomosed to the V3 portion of the VA that traveled under the periosteum at the supra-auricular region through an artificial vessel. After RA-M2 anastomosis, an alternative EC-IC bypass, the V3-RA-M2 bypass, was achieved. Results Postoperative angiography demonstrated successful graft patency and no perioperative complications were observed in both cases. Conclusions In the cases where a high-flow bypass is required, the V3 portion of the VA is a suitable alternative proximal anastomosis site when the ECA is not a candidate donor. Furthermore, an artificial vessel shows satisfactory protection against graft complications. [ABSTRACT FROM AUTHOR]

Our recent studies indicated that a high-riding vertebral artery (HRVA) is a common variant posing a risk of injuring the vessel during C2 instrumentation. However, several different types fit in the current definition of HRVA, which may require a different strategy for C2 screw placement. To classify HRVA and provide a clinical aid for preoperative planning of C2 instrumentation. A secondary goal was to estimate coexistence of each HRVA type with the ipsilateral narrow C2 pedicle (NP). A retrospective observational study involving radiologic measurements of the estimated number of anonymized cervical computed tomography (CT) scans. STROBE checklist was applied. A total of 908 potential screw insertion sites (PSIS) of 454 consecutive cervical CT scans were analyzed. The sample size was estimated using ScalaR SP function in RStudio. Three types of HRVA based on a series of C2 vertebral morphological parameters including the C2 isthmus height (C2IsH) and C2 internal height (C2InH). Also, the prevalences of each HRVA type and coexisting NP based on the C2 pedicle width (C2PW). HRVA was defined as C2IsH of ≤5 mm and/or C2InH of ≤2 mm measured 3 mm lateral to the lateral border of the spinal canal. A narrow pedicle was defined as C2PW of ≤4 mm. Measurements were done using Syn.govia software. Interobserver, intraobserver, and inter-software agreement coefficients for C2IsH, C2InH, and C2PW parameters were adopted from our previous study. K-means cluster analysis was applied. Prevalence of at least 1 HRVA was 24.9% (n=113 subjects) and 16.2% of PSIS (n=147 sites). Based on the measurements and K-means clustering, the following 3 types of HRVA have been distinguished: type 1—isthmic with only C2IsH being reduced and normal C2InH; type 2—internal with only C2InH being reduced and C2IsH within normal limits; type 3—isthmo-internal with both C2IsH and C2InH being reduced. Kruskal-Wallis test followed by unadjusted and Bonferroni-adjusted posthoc multiple comparison analysis detected significant differences across the types. The prevalences of the newly identified types were as follows: 78.2%, 8.8%, and 12.9% for type 1, type 2, and type 3, respectively. 73.9% of type 1 HRVA, 53.8% of type 2 HRVA, and 100% of type 3 HRVA had a concomitant ipsilateral NP. Prediction of the HRVA types by the K-means clustering has been evaluated. Screw placement techniques for each type are proposed and discussed. We present the first classification system for the high-riding vertebral artery distinguishing 3 types based on the large homogenous cohort, which may serve as an adjunct to preoperative planning of C2 instrumentation. External validation of this classification scheme shall determine its further clinical utility. [ABSTRACT FROM AUTHOR]

Migraines being a possible risk factor for spontaneous multivessel cervical artery dissection has been previously introduced but rarely discussed in literature. We present the case of a 32-year-old man with a history of migraines and a 2-week history of bilateral neck pain who was found to have bilateral Vertebral Artery dissection by CT angiography. The patient's stroke's etiology was spontaneous dissection followed by thromboembolism caused by bilateral Posterior Cerebral Artery (P1) occlusion. Due to an inability to protect his airway, he was scheduled to have a tracheostomy and percutaneous endoscopic gastrostomy (PEG). Over the following weeks, the patient continued to be unresponsive to stimuli, unable to follow commands, and unable to exhibit active/purposeful movement. As a result, the patient was transitioned to inpatient palliative care with total parenteral nutrition. We conducted a systematic literature review querying four databases: MEDLINE, Embase, CINAHL, and Academic Search Complete. Eligibility criteria were applied based on article type, title, abstract, and full text screening. Four case reports and three case-control studies discussing patients with a past medical history of migraines presenting with unilateral or bilateral vertebral artery dissection were identified and included in this review. We describe the possibility of the patient's migraine history and potentially associated vasculopathy as a predisposing factor in the development of Vertebral Artery Dissection. Further research is needed to fully understand the exact mechanism occurring that predisposes migraine patients to spontaneous arterial wall injury. [ABSTRACT FROM AUTHOR]

Background: The optimal treatment of complicated type B aortic dissection (cTBAD) involving arch anomalies remain unclear. Methods: We consecutively enrolled patients with cTBAD involving arch anomalies who underwent endovascular repair using a single-branched stent graft (SBSG) at our medical center between January 2020 and January 2023. The demographics, clinical manifestation, operation detail, and follow-up outcomes of these patients were retrospectively collected and analyzed. Results: A total of 16 patients (14 men; 55.8 ± 11.7 years) were enrolled, including isolated left vertebral artery (ILVA) (n = 6), aberrant right subclavian artery (ARSA) (n = 7), and right aortic arch and aberrant left subclavian artery (ALSA) with Kommerell's diverticulum (KD) (n = 3). Among them, six patients with multi-branched arch anomalies. The endovascular management strategies of patients were diverse based on their aortic morphology. The early outcome demonstrated that one patient experienced an immediate intraoperative type Ia endoleak, which was resolved by balloon dilation, and two patients exhibited bird-beak configuration. After a median of follow-up of 910 (743–1023) days, the long-term outcome revealed that two patients developed endoleak. No death, retrograde type A aortic dissection (RTAD), paraplegia, stent graft-induced new entry tear (SINE), or branch section stenosis of SBSG were observed during the follow-up. Conclusion: Our limited experience suggests that endovascular repair with a SBSG appears to be a relatively safe, feasible, and effective treatment option for patients with cTBAD and arch anomalies. [ABSTRACT FROM AUTHOR]

Background: Craniocervical junction (CCJ) dural arteriovenous fistulas (DAVFs) represent a rare yet critical vascular anomaly that may result in significant neurological impairments. Method: We report the case of a 52-year-old male with a history of medullary hemorrhage who underwent surgical intervention for a left CCJ DAVF. Through comprehensive surgical planning and meticulous intraoperative monitoring, multiple feeders of the DAVF were safely coagulated and transected, with successful DAVF obliteration confirmed by intraoperative angiography. Conclusion: The patient demonstrated full recovery, underscoring the efficacy of surgical management in complex cases facilitated by advanced techniques in a hybrid operating theatre. [ABSTRACT FROM AUTHOR]

To investigate the clinical efficacy and safety of microsurgical surgery in patients with proximal vertebral artery stenosis unsuitable for endovascular treatment. A retrospective analysis was conducted on the clinical data of 34 patients with proximal vertebral artery stenosis who underwent microsurgical surgery at the Department of Cerebrovascular Surgery, Shengli Oilfield Central Hospital, Dongying, Shandong, from March 2020 to April 2023. Preoperative imaging confirmation of proximal vertebral artery stenosis or occlusion was obtained using cervical CT angiography (CTA), CT perfusion imaging (CTP), and magnetic resonance angiography (MRA). Postoperative imaging examinations were utilized to evaluate blood flow patency, and clinical symptoms and complications during hospitalization and follow-up were documented. Postoperative imaging examinations in the 34 patients (Males: 79.4%; Mean age: 66.7 ± 9.6 years) revealed patent vertebral and supplying arteries. No new instances of transient ischemic attacks (TIAs) or other cerebrovascular events were observed during hospitalization, and clinical symptoms were improved. The mean follow-up duration was 10 months (range: 6–39 months). One patient died from septic shock due to abdominal infection, and one patient exhibited moderate ipsilateral vertebral artery stenosis on a follow-up CTA at 6 months postoperatively. The Modified Rankin Scale (mRS) scores decreased for 30 patients after surgery compared to preoperative scores, with all postoperative mRS scores being less than 1. The difference between preoperative and postoperative mRS scores was statistically significant (P < 0.01). Six patients experienced temporary postoperative complications, which resolved after active treatment, and one patient developed permanent Horner's syndrome without affecting the quality of life. Microsurgical surgery for patients with proximal vertebral artery stenosis, when endovascular treatment is unsuitable, demonstrates good clinical efficacy and a low incidence of complications, offering a viable surgical treatment option. Further multicenter studies with larger sample sizes will be instrumental in validating its clinical application value. [ABSTRACT FROM AUTHOR]

Background: The far-lateral approach, frequently employed by skull base surgeons, targets lesions in the ventrolateral region of the craniovertebral junction (CVJ). Although various incisions can be utilized, the linear incision is notably less invasive and more efficient. Despite its advantages, the literature lacks a comprehensive description of the technical steps involved in this approach. Methods: We discuss the pertinent surgical anatomy and provide a step-by-step intraoperative description of performing the linear incision far-lateral approach, accompanied by clear intraoperative photographs. Conclusion: The linear incision for the far-lateral approach reduces the extent of soft tissue dissection while having a negligible impact on surgical exposure. Key factors for ensuring the procedure safe and effective include: (1) a comprehensive understanding of the surgical anatomy in the suboccipital region and accurate identification of the midline from this specific position and incision; and (2) employing the "interfascial-subperiosteal-interdural dissection" technique to manage the soft tissues around the CVJ, thereby minimizing the risk of vertebral artery injury. [ABSTRACT FROM AUTHOR]

ABSTRACT Objectives Methods Results Conclusions To minimize the risk of V3 segment of vertebral artery (VA) injury in the atlantoaxial dislocation (AAD) patients with C1 pedicle height less than 4.0 mm and provide a strong toggle force in irreducible AAD and revision surgery. We evaluated the feasibility of C1 “Zero Angle” screw (C1ZAS) and safe entry point with “in–out–in” technique as an alternative option for C1 pedicle screw (PS) in cases with AAD.Sixty‐one patients with AAD or atlantoaxial instability (AAI) (45 male and 16 female) who underwent cervical computed tomography and magnetic resonance imaging scans in our center between January 1, 2022 and December 31, 2023 were retrospectively reviewed. Measurements were made around the ideal trajectory and entry point of C1ZAS using computerized tomography (CT) and magnetic resonance imaging (MRI) in 61 patients. Radiographic measurements included (A) the distance from the recess to the transverse foramen (RTF); (B) the tricortical screw zone (TSZ); (C) the lateral mass height along the C1ZAS trajectory (LMH); (D) the screw length of C1ZAS (ZSL); (E) the screw length of C1 PS (PSL); (F) the distances from the recess to the dura (RD); (G) the distance from the recess to the spinal cord (RSC); (H) the distance from the inner of lateral mass to the spinal cord (ILMSC). During the period of January 1, 2022 to December 31, 2023, C1ZAS placement with “in–out–in” technique was used as an alternative option for C1 PS in 8 patients with AAD and unilateral/bilateral narrow C1 pedicles.The average RTF, TSZ, LMH, ZSL, RD, RSC, and ILMSC were 7.71, 6.14, 8.32, 33.23, 4.68, 10.02, and 2.91 mm respectively. The entry point of the C1ZAS was defined as the projection point of the inner of the recess to the posterior arch and the trajectory should be angled cephalad by 8.7° and medially by 0°. The 61 patients (122 sides) with AAD or AAI were classified into three groups: the low‐risk (76 sides, 62%), the intermedial‐risk (18 sides, 15%), and the high‐risk (28 sides, 23%) groups. Satisfactory C1ZAS placement and atlantoaxial reduction were achieved in all eight patients with AAD and unilateral/bilateral narrow C1 pedicles. No instance of C1ZAS placement‐related VA injury or dural laceration was observed.When the placement of C1 PS is not feasible in patients with AAD and unilateral/bilateral narrow C1 pedicles, C1ZAS placement with “in–out–in” technique can be considered an effective alternative option, providing tricortical or quadricortical purchase for rigid fixation of the atlas. [ABSTRACT FROM AUTHOR]

Vertebral artery injuries (VAI) can occur due to cervical spine trauma. VAI can prove a serious complication and potentially compromise vascular supply to the posterior aspect of the brain. Currently, there is a paucity of evidence with regards to incidence, management, and outcomes for these patients. The purpose of this study is to investigate and elucidate the incidence of VAI associated with cervical trauma at a national tertiary referral centre for spinal pathology, their respective management, and associated outcomes. A retrospective review was conducted from 2012 to 2021 to identify patients with VAI secondary to cervical spine trauma. Demographic, clinical, and radiological data was collected to identify common traits in injury characteristics and management. 1013 spine patients presented to our institution across the 10-year period. 739/1013 (72.9 %) were trauma patients. 42/739 (5.7 %) were imaged for suspected VAI secondary to trauma. There were 14/739 (1.9 %) confirmed VAI. All patients had CT-angiography for diagnosis. Four of the confirmed VAI patients (28.6 %) had additional MR-angiography imaging. Right-side was the most common side of VAI injury (7/14; 50 %), followed by left (5/14; 35.7 %) and bilateral (2/14; 14.3 %) injuries. 8/14 (57.1 %) patients were prescribed anti-thrombotic therapy. Acute mortality within 3-months was noted to be 2/14 (14.3 %) and occurred at 49 days and 57 days respectively. VAI associated with cervical spine injury is rare in occurrence. However, it can be associated with high morbidity and mortality. As such, a multi-disciplinary approach to care is integral to ensuring good outcomes in these patients. • 1013 patients presented to a national tertiary spine unit between 2012 and 2021. • 5.7 % were imaged for suspected VAI, 1.9 % were diagnosed with confirmed VAI. • All cases had surgery and 57.1 % were prescribed anti-thrombotic therapy. • VAI has high morbidity and mortality. Acute mortality at 3 months was 14.3 %. • A multi-disciplinary approach is integral to ensuring good outcomes in this cohort. [ABSTRACT FROM AUTHOR]

Purpose: Identification of the Adamkiewicz artery before aortic surgery is important for preventing postoperative complications due to spinal cord ischemia. The Adamkiewicz artery is difficult to identify due to its small diameter. Nitroglycerin has a vasodilatory effect and is used clinically to improve visualization of blood vessels on coronary computed tomography (CT) angiography. We investigated whether the vasodilatory effect of nitroglycerin could improve the ability to visualize the Adamkiewicz artery. Methods: We extracted 33 cases wherein contrast-enhanced CT images were taken before and after aortic aneurysm surgery. Nitroglycerin was administered for coronary artery evaluation on the preoperative CT. However, no nitroglycerin was administered before the postoperative CT. Aortic contrast-to-noise ratio, CT value, image noise, and diameter of the Adamkiewicz artery and anterior spinal artery were measured. The depiction of the Adamkiewicz artery was graded into four grades and evaluated. These measurements were performed by two independent reviewers. Results: In nitroglycerin-administered cases, the contrast-to-noise ratio and CT values were significantly higher (P < 0.001, P < 0.001, respectively); the Adamkiewicz artery and anterior spinal artery diameters were dilated (P = 0.005, P = 0.001, respectively). The Adamkiewicz artery score also improved significantly (P < 0.001). No significant difference was found in image noise. Conclusion: Nitroglycerin contributed to improving the Adamkiewicz artery's visualization. [ABSTRACT FROM AUTHOR]

Variations at the junction of embryonic internal carotid and vertebrobasilar systems are rare and associated with a high incidence of stroke. During cadaver dissection, we demonstrated for the first time a case of hypoplastic right vertebral artery associated with partial duplication of the distal part of the right P1 segment of a partial fetal posterior cerebral artery (FPCA) and bilateral duplication of superior cerebellar arteries (SCAs), of which, the upper right SCA originated from PCA. We hypothesize that the poor development of the right half of the vertebrobasilar system caused the persistence of FPCA with anomalous origin of the right upper SCA as well as partial duplication of P1 segment of PCA as a remnant of the weak anastomosis between the embryonic right PCA and the basilar system. Such complex variations provide a huge challenge in their diagnosis and in choosing the suitable treatment modality for the stroke. [ABSTRACT FROM AUTHOR]

Neurologists encounter a range of neurological disorders triggered by head and neck movement, reflecting an array of underlying pathologies and producing diverse symptoms. This article provides a practically orientated review of 14 disorders and how to diagnose and manage them, including common disorders such as benign paroxysmal positional vertigo and uncommon entities such as arterial compression syndromes leading to stroke or syncope, mobile intraventricular masses and medication withdrawal states. The article considers atypical scenarios including unusual manifestations and important mimics and discusses controversial entities, as well as the risk of misattributing symptoms based on incidental imaging abnormalities. Guidelines are referenced where they exist, while in rarer situations, approaches taken in published cases are described, with the acknowledgement that management decisions are at the clinician's discretion. [ABSTRACT FROM AUTHOR]