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Subclavian artery aneurysms are extremely rare, accounting for less than 1% all of peripheral aneurysms. They are often due to atherosclerosis or thoracic outlet syndrome and present at an average age of 47 years. Here, we present an incidental finding of an 18 mm rapidly increasing aneurysm involving the first and second part of the right subclavian artery in a woman in her 20s. To our knowledge, this is the youngest patient presenting with a right subclavian artery aneurysm who underwent surgical resection of the aneurysm with repair using interposition graft and successful re-implantation of the vertebral artery with antegrade flow. This report highlights the multidisciplinary care between vascular, interventional radiology and cardiothoracic teams at our tertiary hospital due to the complex nature of the aneurysm. [ABSTRACT FROM AUTHOR]

Background and purpose: Stenting appears to be a safe treatment for vertebral artery ostial stenosis (VAOS) with low complication rates and positive long-term effects. However, in-stent restenosis (ISR) after stenting is common. Drug-coated balloons (DCBs) are an effective management strategy for ISR in patients with coronary or carotid disease. In this study, we investigated the feasibility, safety, and effectiveness of DCB-assisted angioplasty for the treatment of ISR after treatment of VAOS. Research Design: The study included patients in the Department of Neurology at Beijing Tsinghua Changgung Hospital who underwent DCB-assisted angioplasty for ISR after previously undergoing stenting for VAOS. We retrospectively analyzed the clinical and functional outcomes in these patients. Results: Fourteen patients were enrolled in the study between January 2018 and April 2022. Five of the patients were female, and the mean age was 69.4 ± 7.5 years. The technical success rate was 100% and the mean operation time was 57.1 ± 29.2 minutes. No perioperative complications were reported. There were no new cases of cerebral infarction or transient ischemic attacks in hospital or during 6 months of follow-up. There were only 2 reports of ISR in the vertebral artery ostium in the 6 months following DCB-assisted angioplasty. The median modified Rankin scale score was 0. Conclusion: DCB-assisted angioplasty may be feasible for treatment of ISR after stenting of the vertebral artery ostium. However, more research is needed to confirm our findings. [ABSTRACT FROM AUTHOR]

The internal jugular vein (IJV) is occasionally used for blood access during catheter ablation. Additionally, accidental injury of the vertebral artery during an IJV puncture is a rare complication that can result in catastrophic events, such as death. However, vascular access complications cannot be completely prevented despite the introduction of ultrasound‐guided punctures. Here, we present a case of a patient with symptomatic paroxysmal atrial fibrillation that required catheter ablation. [ABSTRACT FROM AUTHOR]

Objective: This retrospective study examines the impact of microsurgical treatment on vertebral artery (VA) dolicoarteriopathies and associated restless leg syndrome (RLS) in patients with refractory vertebrobasilar insufficiency (VBI). Patients and Methods: We analyzed 78 patients with grade 2 and 3 kinks, and found out that the targeted microsurgical interventions, primarily designed to address VBI, improved secondary RLS symptoms in 12 patients. Procedures included arteriolysis and, depending on severity, grafting. Statistical analysis was conducted using Stata 16 (StataCorp LP, Texas, USA). Results: In twelve patients aged 55 to 72 years with refractory VBI and drug-resistant RLS, micro-neurosurgical correction of V1 segment dolicoarteriopathy, abnormal elongation and kinks in the artery, demonstrated promising outcomes. Postoperatively, 83.33% (10 patients) reported complete resolution of RLS symptoms, and 16.66% (2 patients) experienced partial symptom relief (p<0.05). Overall, 86.8% of various VBI-related symptoms were significantly improved or resolved (p<0.05). The microsurgical technique, avoiding traditional flow-arresting procedures, proved to be highly effective in this preliminary study with no mortality and minimal temporary complications, underscoring its potential treatment avenue for such complex neurovascular conditions. Conclusion: This study illuminates the relationship between VBI and RLS, proposing a potential vascular etiology for RLS, and highlights the need for a broader diagnostic approach for patients with refractory VBI. [ABSTRACT FROM AUTHOR]

Objective To report 4 cases of intracranial arterial stenosis stenting via radial artery approach and summarize the experience of treatment. Methods and Results The clinical data and treatment process of 4 patients with ischemic stroke treated by intracranial arterial stenosis stenting via radial artery approach in The Affiliated Hospital of Qingdao University were reviewed in 2022. The stenoses were located in the initial segment of left internal carotid artery (ICA), the initial segment of right vertebral artery (VA), the V4 segment of left VA, and the junction of V4 segment of left VA and the basilar artery, respectively. All the 4 patients underwent transradial approach stenting for ICA stenosis. The surgery was successful and the stenoses were recanalized. No adverse reactions were observed during and after the surgery. Conclusions Intracranial arterial stenosis stenting via radial artery approach is safe and effective in the treatment of ischemic stroke. [ABSTRACT FROM AUTHOR]

Background Among acute vertebrobasilar artery occlusion (VBAO) patients, successful reperfusion is a strong predictor of favorable outcomes. However, failed reperfusion (FR) with endovascular thrombectomy (EVT) in VBAO was observed to occur in 18-50% of cases. We aim to evaluate the safety and efficacy of rescue stenting (RS) for VBAO after failed EVT. Methods Patients with VBAO who received EVT were enrolled retrospectively. Propensity score matching was performed as the primary analysis to compare the outcomes between patients with RS and FR. Furthermore, a comparison between using the self-expanding stent (SES) and balloon-mounted stent (BMS) in the RS group was also conducted. The primary and secondary outcomes were defined as a 90-day modified Rankin Scale (mRS) score 0-3, and a 90-day mRS score 0-2, respectively. Safety outcomes included all-cause mortality at 90 days and symptomatic intracranial hemorrhage (sICH). Results The RS group showed a significantly higher rate of 90-day mRS score 0-3 (46.6% vs 20.7%; adjusted OR (aOR) 5.06, 95% CI 1.88 to 13.59, P=0.001) and a lower rate of 90-day mortality (34.5% vs 55.2%; aOR 0.42, 95% CI 0.23 to 0.90, P=0.026) than the FR group. The rates of 90-day mRS score 0-2 and sICH were not significantly different between the RS group and FR group. There were no differences in all outcomes between SES and BMS groups. Conclusions RS appeared to be a safe and effective rescue approach in patients with VBAO who failed EVT, and there was no difference between using SES and BMS. [ABSTRACT FROM AUTHOR]

Abstract: Vertebral artery fenestration (VAF) is a type of anomaly of the vertebral artery in which a segment of the vessel divides into two separate channels that join together later in the course. Neurenteric cysts are rare, congenital lesions arising within the spinal canal usually in the cervical region. Vertebral artery anomalies if not considered during operative planning can lead to iatrogenic injury. We report a case of a 5-year-old boy who presented with a history of acute onset, non-traumatic spastic quadriparesis. Examination revealed the presence of cervical neurenteric cyst present ventrally at C1–C3 level. Further workup revealed the presence of bilateral VAF with the fenestrated part going along the inferior aspect of the arch of atlas bilaterally. Surgical excision of the lesion was done taking into consideration the anomalous course of vertebral artery. VAFs are classified according to their location as intracranial or extracranial and according to the segment of the vertebral artery from which they arise (V1–V4). Iatrogenic injury to the vertebral artery has been reported during both anterior and posterior approaches to the cervical spine. Due consideration should be given to anomalous course of vertebral artery while planning the surgical approach in craniovertebral junction. [ABSTRACT FROM AUTHOR]

Background To explore the incidence, predictors, and association of first pass effect (FPE) on clinical outcomes of mechanical thrombectomy (MT) for acute vertebrobasilar artery occlusion (VBAO) in the Asian population. Methods We selected patients from the ANGEL-ACT registry. We defined FPE as complete recanalization after one MT attempt without rescue treatment, multiple pass effect (MPE) as complete recanalization after >1 MT attempt or after one MT attempt with rescue treatment, and incomplete recanalization (ICR) as a modified Thrombolysis in Cerebral Ischemia score of 2b, independent of the number of MT attempts. We conducted multivariable logistic analyses to identify the independent predictors of FPE and to compare the outcomes, including favorable outcome, mortality within 90 days, and intracranial hemorrhage (ICH) among the FPE, MPE, and ICR groups. Results Two hundred and seventy-nine patients, 68 with FPE (24.4%), 114 with MPE (40.9%), and 83 with ICR (29.7%), were included. Underlying intracranial atherosclerosis disease (ICAD) (adjusted OR (aOR) 0.16, 95% CI 0.08 to 0.34, P<0.001) was independently associated with a low chance of FPE. Furthermore, FPE was associated with a favorable outcome compared with MPE and ICR (MPE vs FPE, aOR 0.49, 95% CI 0.25 to 0.97, P=0.040; ICR vs FPE, aOR 0.38, 95% CI 0.18 to 0.81, P=0.012), and decreased mortality (MPE vs FPE, aOR 2.57, 95% CI 1.04 to 6.36, P=0.041) compared with MPE but similar mortality to ICR (P=0.374). No difference was found for ICH among the three groups (P>0.05). Conclusions FPE occurred in 24.4% of patients with VBAO in our cohort, which was associated with improved clinical outcomes compared with MPE and ICR. VBAO with underlying ICAD was less likely to achieve FPE. Trial registration number NCT03370939. [ABSTRACT FROM AUTHOR]

Background Few studies have focused on the effect of systemic inflammation in vertebrobasilar artery occlusion (VBAO). The aim of this study was to investigate the relationship between inflammatory indicators and the prognosis of VBAO patients receiving endovascular treatment (EVT). Method Patients with VBAO who were treated with EVT within 24 hours of the estimated occlusion time were included in this study. Multivariate logistic regression and elastic net regularization were performed to analyze the effects of inflammatory indicators on the prognosis of patients with VBAO. The primary outcome was unfavorable outcome (a modified Rankin Scale score of 4-6) at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage, in-hospital mortality, 90 day mortality, 1 year unfavorable outcome, and mortality. Results 560 patients were included in the study. Multivariate analysis showed that white blood cells (W), neutrophils (N), neutrophil to lymphocyte ratio (NLR), platelet to neutrophil ratio, platelet to white blood cell ratio, and NLR to platelet ratio were associated with the primary outcome. Elastic net regularization indicated that W, N, and NLR were the major inflammatory predictors of unfavorable outcome at 90 days. For long term prognosis, we found that the inflammatory indicators that predicted 1 year outcomes were consistent with those that predicted 90 day outcomes. Conclusion Inflammatory indicators, especially W, N, and NLR, were associated with moderate and long term prognosis of patients with VBAO treated with EVT. [ABSTRACT FROM AUTHOR]

Background The effects of secondary collateral compensation on outcomes remain unclear in patients with acute basilar artery occlusion (BAO) after endovascular treatment (EVT). This study aimed to evaluate the benefits of the anastomosis between the posterior inferior cerebellar artery (PICA) and the superior cerebellar artery (SCA) in BAO after EVT. Methods This cohort study was conducted using data from the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry. Patients with acute BAO and treated with EVT were included. The primary outcome was a modified Rankin Scale score of 0-2 at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (SICH) and 90-day mortality. Results Of the 646 patients included in the study, 196 (30.3%) patients had a PICA-SCA anastomosis. The PICA-SCA anastomosis was significantly associated with independent functional outcome at 90 days (67/196 (34.2%) vs 109/450 (24.2%), adjusted OR (aOR) 1.80 (95% CI 1.13 to 2.86), p=0.01) and was significantly associated with a decreased rate of SICH (40/442 (9.0%) vs 5/193 (2.6%), aOR 0.29 (95% CI 0.11 to 0.76), p=0.01). No significant difference was found between PICA-SCA anastomosis and 90-day mortality (219/450 (48.7%) vs 80/196 (40.8%), aOR 0.72 (95% CI 0.48 to 1.08), p=0.11). Subgroup analysis showed that the association between independent functional outcome and PICA-SCA anastomosis was strongest in patients with middle BAO (27/77 (35.1%) vs 22/118 (18.6%), aOR 2.64 (95% CI 1.13 to 6.15), p=0.03). Conclusions The PICA-SCA anastomosis is significantly associated with better functional outcomes in patients with acute BAO after EVT, especially in those with middle BAO. [ABSTRACT FROM AUTHOR]

The twisting phenomenon of the flow diverter stents rarely occurs, but it recently became relatively well-recognized. There have been few reports on single-layer flow diverters only. The Flow Redirection Endoluminal Device (FRED) (MicroVention, Tustin, California) has a unique design characterized by a braided dual-layer self-expanding stent. There have been no reports on the twisting phenomenon of FRED. This study reports two cases of acute in-stent blood flow disturbances after the deployment of FRED in a patient with intracranial aneurysms associated with "ghost twisting." In this phenomenon, the inner layer does not expand with the coning deformation, even though the outer layer is fully open. This was confirmed through high-resolution cone-beam computed tomography, but not conventional angiography. The two cases were successfully treated using balloon angioplasty and showed favorable outcomes. The structural issue of "ghost twisting" was a possible underlying factor for the ischemic complications associated with FRED deployment. [ABSTRACT FROM AUTHOR]

Vertebral artery (VA) injuries in penetrating trauma are rare but can be life threatening. Management is often reliant on interventional radiology (IR), although such services may be lacking in peripheral centres. We report a case of a 22-year-old man who sustained a right VA injury from a stab wound to the posterolateral neck that was managed in a rural hospital. On presentation, the patient was initially haemodynamically stable but began exsanguinating heavily whilst undergoing imaging and was subsequently transferred to the operating theatre. Intraoperatively, bleeding was noted from the C5/C6 interforaminal space. Due to difficulty with exposure and lack of specialist surgical services, bimanual pressure was continuously applied to the wound whilst awaiting the arrival of a vascular surgeon and neuro-interventionalist who were transported by air from a tertiary hospital. At the time of angiography, bleeding had ceased and no further intervention was required. This case highlights the importance for surgeons in peripheral centres to be aware of some of the operative manouvres used in managing VA injuries including the utility of continued direct pressure. Moreover, it serves as a reminder that there remains a role for operative intervention in the unstable patient despite increasing reliance on radiological techniques to treat such injuries. [ABSTRACT FROM AUTHOR]

Objective To propose a nomogram for individual risk assessment of in-stent restenosis (ISR) after vertebral artery origin stenosis (VAOS) stenting. Methods We included 793 patients with VAOS treated with stenting from October 2006 to May 2013, with a median follow-up of 27.8 months. Cox regression and the least absolute shrinkage and selection operator (LASSO) regression were adopted for variable selection. The nomogram was formulated and validated by concordance indexes (C-indexes) and calibration curves. An in-stent restenosis risk table (ISR-RT) was subsequently generated for risk stratification. Differences between low-, intermediate-, and high-risk levels were shown by Kaplan-Meier curves and compared by log-rank test. Results The training and validation set included 594 and 199 patients, with a mean ISR rate of 37.2% and 35.2%, respectively. Stent type (HR=1.64, 95% CI 1.26 to 2.14), stent diameter (HR=2.48, 95% CI 1.77 to 3.48), history of peripheral vascular disease (HR=2.17, 95% CI 1.17 to 4.00), history of transit ischemic attack (HR=1.45, 95% CI 1.05 to 2.14), and left-side involvement (HR=1.33, 95% CI 1.04 to 1.69) were included in the nomogram. The C-indexes at 6 and 12 months were 0.650 and 0.611 in the training set, and 0.713 and 0.603 in the validation set, respectively. Compared with low-risk patients, the intermediateand high-level group had 1.46 (95% CI 1.05 to 2.04; p=0.0235) and 2.28 (95% CI 1.64 to 3.17; p<0.0001) higher chances of developing ISR in 2 years, respectively. Conclusions A nomogram and a risk evaluation table were developed with good predictive ability for in-stent restenosis among patients with VAOS, which could serve as a practical approach for individualized risk evaluation. [ABSTRACT FROM AUTHOR]

Background:  The study aimed to evaluate the safety and feasibility of transpedicular instrumentation for the C2 vertebra and to establish the precise anatomical parameters and boundaries within which this procedure can be safely and effectively performed., Methods:  This retrospective study analyzed 66 patients who underwent C2 transpedicular screw fixation. Preoperative and postoperative axial, sagittal, and coronal computed tomography (CT) scans were examined. Anatomical measurements were taken to determine the horizontal and vertical distances from the C2 pedicle projection to the vertebral foramen using CT images. Based on the anatomical location of the vertebral artery within the C2 vertebral foramen, the patients were divided into four subgroups using the horizontal pedicle width (HPW) and vertical pedicle width (VPW) of the C2 spine., Results:  The average age of the patients included in the study was 46.48 years. The patient population comprised 32 (48.5%) males and 34 (51.5%) females. Based on the anatomical measurements, the distribution of C2 vertebra types was as follows: type 1 accounted for 68.9%, type 2 for 3.8%, type 3 for 16.7%, and type 4 for 10.6%. Significantly narrower pedicle widths were observed in types 2 and 4 compared to other vertebra types. Type 2 had the largest medial angle (MA), while type 4 had the narrowest MA. In terms of the sagittal plane, type 4 exhibited the widest MA and type 3 had the narrowest MA, but these differences were not statistically significant. Among the cases, 12 (18.1%) involved the vertebral foramen, with 1 case (8.3%) showing screw-related vertebral artery injury (0.75% of all screws). No vertebral artery injuries were observed with the other transpedicular screws., Conclusion:  Preoperative anatomical measurements for patients undergoing transpedicular instrumentation on the C2 vertebra should include planning CT images on three planes: axial, sagittal, and coronal., Competing Interests: None declared., (Thieme. All rights reserved.)

Background and Importance: Partially thrombosed vertebral artery aneurysms (PTVAs) are rare, most of which are not easy to treat. Furthermore, endovascular treatment of PTVAs may not have favorable outcomes. The relationship between PTVAs and well-developed vasa vasorum (VV), including the mechanism of aneurysm growth, has been reported, but there are no reports of imaging findings by digital subtraction angiography (DSA). In this case, we successfully performed superselective angiography of well-developed VV and evaluated its imaging characteristics. We present the first DSA report of a well-developed VV of PTVA., Clinical Presentation: A 54-year-old patient presented with a PTVA that exerted a mass effect on the medulla oblongata. The aneurysm had no cavity due to thrombosis. The 3-dimensional DSA images indicated VV. Superselective angiography of the VV indicated staining of the thrombosed aneurysm and draining into the suboccipital cavernous sinus through the venous VV. Thus, VV embolization with n-butyl cyanoacrylate was performed. After 3 months, the contrast effect of the aneurysm on contrast-enhanced magnetic resonance imaging disappeared and aneurysm shrinkage was observed., Conclusion: We successfully identified a VV within PTVA. Superselective VV angiography showed staining of the thrombosed component and venous return draining into the suboccipital cavernous sinus. In this case, the embolization of the VV proved to be an effective endovascular treatment of PTVA, but the safety of this method is a challenge. Further case studies are required to validate this method, and we hope it will evolve into a new treatment of PTVA., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: To investigate the morphological characteristics and operative outcomes of acute type A aortic dissection (ATAAD) in patients with aortic arch variants., Methods: Of 616 patients with ATAAD, 97 (15.7%) had aortic arch variants, including bovine aortic arch (BAA, n = 66), isolated left vertebral artery (ILVA, n = 25), and aberrant subclavian artery (ASA, n = 6). The characteristics and outcomes were compared between the normal branching group (control, n = 519) and the total/individual arch variant groups., Results: Compared to the control group, arch entry was more prevalent in the BAA (18.5% vs. 31.8%) and ILVA groups (44%) (both, P < 0.05), and right common carotid arterial occlusion was less common in the arch variant group (6.7% vs. 0%, P = 0.017). The in-hospital mortality (9.2% vs. 9.3%), new-onset stroke (7.3% vs. 7.2%), and 5-year survival (81.7% vs. 78.8%) did not differ markedly between the control and arch variant groups. Arch repair was performed in 28.9% (28/97) of the arch variant group using 3-4 vessel antegrade cerebral perfusion, with 3.8% in-hospital mortality and a 15.4% stroke rate, which were comparable to those of the control group., Conclusions: Aortic arch variants may influence tear location and involvement of the supra-arch vessels but may not affect postoperative outcomes., Competing Interests: Declarations. Conflict of interest: None declared., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Rationale: Vertebral artery loop formation (VALF) compresses the adjacent cervical nerve root, resulting in cervical radiculopathy at the affected level. Neurosurgical interventions for anatomical separation are typically employed to relieve the symptoms, regardless of their duration. We herein report the management of the subacute symptoms of a rare case of cervical radiculopathy attributed to VALF using integrative Korean medicine (iKM) treatment without surgery., Patient Concerns: A 54-year-old male patient presenting with a chief complaint of headache radiating to the posterior cervical and right scapular regions was treated with a 4-day program of inpatient care., Diagnoses: Based on the findings of the cervical spine magnetic resonance imaging, the patient was diagnosed with VALF on the right side at the C3/C4 level., Interventions: He underwent iKM treatment comprising acupuncture, pharmacopuncture, Chuna therapy, and herbal medicine., Outcomes: Significant improvement was noted in the patient's condition (neck pain Numeric Rating Scale scores of 5, 4, and 1; Neck Disability Index scores of 35.56, 20, and 4; and EuroQol 5-dimension index scores of 0.754, 0.787, and 0.862 at admission, discharge, and the 2-month follow-up, respectively; Patient Global Impression of Change scores of 3 and 1 at discharge and the 2-month follow-up, respectively)., Lessons: This case report suggests that iKM treatment may be effective for subacute VALF symptoms without requiring surgery., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2025 the Author(s). Published by Wolters Kluwer Health, Inc.)

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Objectives: In cases where dumbbell-shaped cervical schwannoma encases the vertebral artery (VA), there is a risk of VA injury during surgery. The objective of this study is to propose a strategy for preserving the VA during the surgical excision of tumors adjacent to the VA through the utilization of anatomic layers., Methods: A retrospective analysis was conducted on 37 patients who underwent surgery for dumbbell-shaped cervical schwannoma with contacting VA from January 2004 to July 2023. The VA encasement group consisted of 12 patients, and the VA nonencasement group included 25 patients., Results: The perineurium acted as a protective barrier from direct VA exposure or injury during surgery. However, in the VA encasement group, 1 patient was unable to preserve the perineurium while removing a tumor adjacent to the VA, resulting in VA injury. The patient had the intact dominant VA on the opposite side, and there were no new neurological deficits or infarctions after the surgery. Gross total resection was achieved in 25 patients (67.6%), while residual tumor was confirmed in 12 patients (32.4%). Four patients (33.3% of 12 patients) underwent reoperation because of the regrowth of the residual tumor within the neural foramen. In the case of the 8 patients (66.7% of 12 patients) whose residual tumor was located outside the neural foramen, no regrowth was observed, and there was no recurrence of the tumor within the remaining perineurium after total resection., Conclusion: In conclusion, when resecting a dumbbell-shaped cervical schwannoma contacting VA, subperineurium dissection prevents VA injury because the perineurium acts as a protective barrier., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objective: This study aims to elucidate the anatomical principles governing the surrounding venous structures (VS) of the horizontal part of the third segment of the vertebral artery (V3h) and develop a safe and bloodless surgical technique for exposing V3h., Methods: This study used 10 formalin-infused cadaveric head specimens. The dissections were performed stepwise to simulate the far lateral approach process, exposing the V3h with a novel technique. Additionally, we applied this technique to 10 patients undergoing far or extreme lateral approaches., Results: The VS surrounding V3h is divided into 3 components: the vertebral venous plexus, suboccipital cavernous sinus, and the anastomotic vein. The posterior atlanto-occipital membrane (PAOM), a resilient fascial layer in the craniovertebral junction, extends from the periosteum of the occipital squama to the posterior arch of the atlas. It adheres ventrally to the VS within the suboccipital triangle (SOT), forming a tent-like structure that maintains tension and ensures fullness of the VS around V3h. We discovered that by releasing tension in this membrane and reducing strain on this tent-like structure, the collapse of the venous sinus within the SOT can be achieved, resulting in reduced intraoperative bleeding and improved surgical efficiency. Additionally, we successfully managed 10 clinical cases employing the PAOM tension release technique in clinical cases, with no reported incidents of intraoperative vertebral artery injury., Conclusions: The application of the PAOM tension release technique effectively collapses the tent-like structure within the SOT, significantly reducing bleeding during V3h exposure in craniovertebral junction., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: In general, the superior cerebellar artery is the most prevalent vessel that compresses the trigeminal nerve root exit zone (TGNREZ) and is responsible for trigeminal neuralgia (TGN). Nevertheless, the surgical outcome is less efficacious when the offending vessel is a dolichoectatic vertebrobasilar vessel (DVB). In addition, the potential for postprocedural adhesion and fibrosis renders recurrent TGN after prior surgery, an extremely challenging operation., Methods: We describe our surgical strategy and procedure that effectively resolved recurrent TGN in a patient whose offending vessel was a large DVB following standard microvascular decompression surgery. The size and nature of the offending DVB indicated that there was limited space for mobilization away from the TGNREZ, as evidenced by previous operative findings. Consequently, the patient's TGN may not be effectively treated by reoperating with the same standard lateral suboccipital approach., Results: Our surgical approach comprised the creation of an expanded area to facilitate the mobilization of the DVB from the TGNREZ, as well as the untethering of the trigeminal nerve and its subsequent mobilization from the DVB using the transposition technique., Conclusions: A combined transpetrosal approach with microneurovascular transposition technique was selected to achieve all objectives. A case illustration with a surgical video is demonstrated., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect and safety of transradial stent angioplasty using double guide wires for severe stenosis of vertebral artery ostium at a lower location., Methods: Patients with severe stenosis of the vertebral artery ostium at a lower location treated with transradial stent angioplasty were retrospectively enrolled. All the clinical and endovascular treatment data were analyzed., Results: Thirty-nine patients were enrolled. A low location of the vertebral artery ostium was present in 33 (84.6%) patients and an ultra-low location in 6 (15.4%). Transradial stent angioplasty was performed in all patients. In one patient who had a tortuous radial artery, the transradial access was failed. In the other 38 (97.4%) patients, transradial stent angioplasty was all successful. The sharp angle formed between the vertebral artery and the subclavian artery was significantly (P < 0.0001) increased from 15° to 65° (36° ± 11°) before to 70-125° (90° ± 17°) after insertion of a support guide wire. No damage was found in all support guide wires. Thirty-nine stents were deployed, and the preoperative stenosis rate of 70%-98% (85% ± 13%) was significantly (P < 0.0001) decreased to 0-25% (16%) immediately after stenting. Six-12 months after surgery, 29 (74.4% or 29/39) patients were followed up with imaging, and 9 (31.0%) patients experienced in-stent restenosis, with endovascular retreatment being performed in 3 (33.3%) patients., Conclusions: Transradial stent angioplasty using double guide wires is safe and effective for the treatment of severe stenosis of the vertebral artery ostium at a lower location even though more studies are necessary to confirm this., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: Angioplasty using drug-coated balloon (DCB) for treatment of symptomatic vertebral artery origin stenosis (VAOS) is promising, but of uncertain benefit. This study aimed to evaluate the feasibility, safety, and effectiveness of using DCB in the treatment of severe VAOS. Methods: This study included 20 patients with severe VAOS treated with DCB alone between April 2018 and December 2019. Vascular death, transient ischemic attack (TIA), and stroke related to the responsible artery within 30 days after procedure were recorded as primary endpoints. Restenosis, late TIA, and stroke related to VAOS and satisfied clinical outcome [modified Rankin Scale (mRS) ≤ 2] were documented at follow-up visit as secondary endpoints. Results: Of 20 patients, 16 were performed DCB dilation successfully, and 4 were excluded due to further bailout stenting. After the procedure, no adverse event occurred within 30 days. Ten of 16 patients achieved residual VAOS (rVAOS) < 50% (lower rVAOS group), and the remaining 6 patients achieved rVAOS ≥ 50% but < 70% (higher rVAOS group). During follow-up, vertebral artery origin restenosis was detected in 3 (18.8%) of 16 patients by ultrasound. Among the 3 patients with restenosis, 2 were belonged to the higher rVAOS group, which might indicate a tendency that the more severe the residual stenosis, the higher the restenosis rate. All patients had no complaint in the whole follow-up period (median, 7 months; InterQuartile Range, 1–18 months). Conclusions: Angioplasty using DCB for VAOS may be feasible, safe, and effective. The degree of residual stenosis after using DCB alone may affect the restenosis rate. [ABSTRACT FROM AUTHOR]

Objective Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). Design Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials. Methods Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA. Results The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success. Conclusions In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA. [ABSTRACT FROM AUTHOR]

Background: C2 pedicle screw placement in patients with basilar invagination (BI) is fraught with risks because of a high incidence of anatomical variations and high-riding vertebral artery (HRVA). However, no study can be found in the literature that attempted to identify the ideal entry point and trajectory through the C2 pedicle in BI patients with HRVA.Purpose: To investigate the parameters of ideal entry point and trajectory for C2 pedicle screw placement in BI patients with HRVA and compare them with those in BI patients without HRVA and patients without BI as control. These parameters would serve as a guide to pedicle screw placement.Study Design: A retrospective comparative study.Patient Sample: A total of 396 patients (198 consecutive BI patients and 198 matched patients without BI as control) and 792 unilateral pedicles from April 2017 to October 2021 at two medical centers were included.Outcome Measures: The insertion parameters of mediolateral angle, surface distance, cephalad angle, and vertical distance from the superior border of the lamina were the primary outcome measures for the reference of C2 pedicle screw placement. Furthermore, factors that affect the primary insertion parameters were assessed via multiple linear regression analyses.Method: According to the diagnosis of BI and HRVA, the unilateral pedicles were assigned into HRVA of BI, non-HRVA of BI, HRVA of control, and non-HRVA of control groups. Subgroup analyses based on Goel types A and B were also performed. Moreover, vertebral artery (VA) anomalies that might result in potentially serious complications were identified and systematically compared.Results: The measurements of insertion parameters in BI patients with HRVA indicated a mean mediolateral angle of 27.42°, a mean cephalad angle of 43.02°, a mean surface distance of 9.74 mm, and a mean vertical distance from the superior border of the lamina of 3.85 mm. Compared with that in BI patients without HRVA, the measurements suggested that the entry point in BI patients with HRVA should be shifted upward by 0.38 mm and the trajectory should be angled cephalad by 6.05° and medially by 4.78°. In the control group, changes in the insertion parameters between HRVA and non-HRVA showed a similar trend to the BI group. Multiple linear regression showed that mediolateral angle was significantly associated with the male gender (B=-0.930, p=.017) and the diagnoses of HRVA (B=6.964, p<.001), Goel type A (B=-1.656, p=.003), and Goel type B (B=0.981, p=.030). Moreover, cephalad angle was significantly associated with the length of lateral mass (B=-0.319, p=.001) and the diagnoses of HRVA (B=3.254, p<.001) and Goel type A (B=6.924, p<.001). The VA anomalies were significantly higher in the BI group than in the control group.Conclusions: The insertion parameters of the ideal entry point and trajectory for C2 screw placement in BI patients with HRVA were remarkably different from those of non-HRVA of BI, HRVA of control, and non-HRVA of control cohorts. Preoperative 3D computed tomography (CT) and CT angiography are highly recommended in such patients to improve intraoperative safety and reduce postoperative complications. [ABSTRACT FROM AUTHOR]

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Background There is little consensus on endovascular treatment for symptomatic intracranial posterior circulation stenosis via the transradial approach (TRA). We report our multicenter experience and technical procedures that directly used a distal access catheter (DAC) via TRA for the treatment of symptomatic intracranial vertebral (VA) and basilar (BA) artery stenosis. Methods From January 2019 to December 2020, 92 consecutive patients with severe symptomatic intracranial VA or BA stenosis were retrospectively collected and divided into two groups (TRA group and transfemoral approach (TFA) group) for neurointerventional treatment. The percentages of catheters reaching the V3/V4 segment of the VA and technical success, postoperative care conditions, preoperative outcomes and complications, long term clinical outcomes, and imaging follow-ups were observed. Results The catheter, CAT 5, reached the V4 segment of the VA in 37 TRA patients (88.1%). The duration of the procedure was significantly shorter in the TRA group than in the TFA group (median 48.0 min vs 55.5 min, p=0.037). More patients in the TRA group could walk within 2 hours after the procedure (85.7% vs 10.0%, p=0.000), and the duration of retaining catheterization in the TRA group was shorter (3.0±1.2 hours vs 11.7±5.6 hours, p=0.000). Conclusion This study demonstrates the potential feasibility and safety of using a DAC via the TRA without guiding support for the treatment of symptomatic intracranial VA and BA stenosis. The TRA demonstrated some advantages over the standard TFA in terms of patient comfort. Further randomized controlled trials comparing the TRA and TFA for posterior circulation stenosis are needed. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the difference in mechanical thrombectomy (MT) outcomes between vertebrobasilar tandem occlusion (VBTO) and isolated basilar artery (BA) occlusion (non-VBTO) and the difference in rates of successful recanalization between the clean-road and dirty-road pathways, in VBTO. Methods: We conducted a meta-analysis after searching PubMed, EMBASE, and Google Scholar databases as of April 2021. We only included adult patients who underwent MT to treat acute ischemic stroke (AIS) due to VBTO, and the following outcomes should be reported: successful recanalization, functional outcome at 90 days, and symptomatic intracerebral hemorrhage (sICH). The main effect size measures were odds ratio and risk difference, and the software used was RevMan 5.4. Results: The analysis included 81 VBTO and 324 non-VBTO patients (seven studies). We found no significant difference regarding 3 m functional independence [4 studies: OR = 1.71 (95% CI, 0.54, 5.43), I2 = 75%], 3 m mortality [4 studies: OR = 1.62 (95% CI, 0.62, 4.25), I2 = 66%], sICH [4 studies: OR = 1.71 (95% CI, 0.67, 4.39), I2 = 0%], and successful recanalization [3 studies: OR = 0.81 (95% CI, 0.12, 5.57), I2 = 80%]. A subgroup analysis of 118 VBTO patients (five studies) showed no significant difference in successful recanalization between clean-road and dirty-road pathways [RD = 0.07 (95% CI, − 0.09, 0.24), I2 = 40%]. Conclusion: The results of this meta-analysis support the use of MT for AIS patients with VBTO. In VBTO patients, none of the clean-road or dirty-road pathways proved to be superior to the other. [ABSTRACT FROM AUTHOR]

Low back pain is one of the most prevalent musculoskeletal ailments in the United States. Intraosseous radiofrequency ablation of the basivertebral nerve is an effective and durable therapy for low back pain and can be offered to patients who have chronic low back pain of greater than 6 months of duration, failure to respond to noninvasive therapies for 6 months, with either Modic Type I or Type II changes at L3–S1. This article reviews the anatomy and physiology, patient selection, technique, and evidence regarding basivertebral nerve ablation. [ABSTRACT FROM AUTHOR]

Extracranial vertebral artery aneurysms are extremely rare and are usually associated with trauma or dissection. Primary extracranial vertebral artery aneurysms are far less common. They may be of mycotic origin or associated with systemic diseases (e.g., neurofibromatosis). The presentation and natural history remain idiopathic, and operative management can be often difficult. Angiography remains the criterion standard in diagnosis and characterization of these lesions. We hereby present a case of a primary aneurysm of the extracranial portion of the vertebral artery and its surgical management, which implied an initial endovascular approach followed by a 2-step surgery to resect the aneurysm and stabilize the spine., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Root exit zone (REZ) compression by a fusiform vertebral artery (VA) aneurysm is a rare cause of hemifacial spasm (HFS). We report a case of successful microvascular decompression (MVD) for the treatment of HFS caused by a fusiform VA aneurysm. We also review the relevant literature and demonstrate the effectiveness of surgical treatment., Case Description: A 64-year-old man presented with a 2-year and 4-month history of progressive involuntary facial twitching on the right side. Radiological examination revealed a fusiform right VA aneurysm. The REZ that was compressed by the aneurysm and the underlying anterior inferior cerebellar artery (AICA) was surgically decompressed by transposing the VA and AICA and wrapping the aneurysm. Immediately post-operation, the patient's symptoms disappeared. For 7 years and 4 months postoperatively, there was no symptom recurrence or increase in aneurysm size., Conclusion: MVD is an effective treatment for HFS caused by a fusiform VA aneurysm because symptoms are likely to improve immediately after treatment.

Summary of Background Data: Iatrogenic injury of the vertebral artery (VA) in the context of surgical approaches to the cervical spine has been cited as a relatively rare complication with varying degrees of severity ranging from minimal injury to acute stroke and can result in death. It is estimated that ~50% of cases of iatrogenic VA injury are preventable after postoperatively examining a patient's preoperative imaging. Despite the low incidence (<2%) of this complication, the potential associated morbidity demonstrates the importance of meticulous preoperative vascular consideration., Objective: This study aims to emphasize the importance of preoperative vascular screening during anterior cervical access planning visualized through a rare case of a VA aberration in a 47-year-old patient., Study Design: This study is designed as a retrospective case report., Methods: A thorough chart review was performed for this subject including all prior medical records, imaging studies, imaging reports, operative notes, and communication records., Results: The subject was found to have a history of patent foramen ovale (PFO) repair with a rare vertebral artery malformation described as a medial transposition of the vertebral artery out of the vertebral artery foramen between C3 and C4., Conclusions: Consideration of cervical anatomy, particularly the VA, is key to minimizing the risk of adverse surgical outcomes in both anterior and posterior approaches to the cervical spine. During the workup process, the patient's primary care providers, radiologists, and surgeons should be aware of the potential variations of the VA with particular attention given to the course of the VA on MR imaging., Level of Evidence: Level IV., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Robotic-assisted surgery has emerged as an innovative approach widely adopted in the field of orthopedics. However, its application specifically for managing atlantoaxial dislocation with a high-riding vertebral artery (AAD-HVA) remains underreported in the existing literature., Objective: To compare the perioperative outcomes of robotic-assisted (RA) and fluoroscopic-guided free-hand (FH) techniques for atlantoaxial dislocation in combination with a high-riding vertebral artery (AAD-HVA)., Study Design: This was a retrospective study., Setting: This research was performed at a single department of spine surgery., Methods: Data from patients who underwent atlantoaxial internal fixation between July 2018 and January 2022 at our hospital were retrospectively analyzed. Among the cases, 14 were performed using free-hand (FH) techniques and 11 utilized robotic-assisted (RA) techniques. Data collected included case notes, imaging records, and follow-up data. The reliability of screw placement was evaluated based on the Gertzbein and Robbins scores, while treatment outcomes were assessed using the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), neck disability index (NDI), and postoperative complication rate., Results: Baseline patient characteristics were comparable between the FH and RA groups. The mean blood loss was markedly lower in the RA group (157.3 ± 49.7 ml) compared to the FH group (290.0 ± 110.3 ml) (p = 0.03). Although the average operative time was slightly higher in FH group than in RA group, this disparity did not achieve statistical significance (p = 0.7588). Moreover, the radiation exposure dose was remarkably higher in FH group (32.7 ± 4.4 mGy) than in RA group (23.0 ± 3.2 mGy) (p < 0.0001). The percentage of clinically acceptable screw placement was slightly lower in FH group (87.5%) than in RA group (97.8%), but the observed variance was not statistically meaningful (p = 0.3669). Furthermore, the differences in JOA, VAS, and NDI scores between the FH and RA groups were not statistically significant. Additionally, no obvious differences were found in clinical outcomes or complications related to screw implantation between the two groups., Limitations: This study has inherent limitations as it was retrospective in nature and conducted at a single center., Conclusion: Robotic-assisted surgery for AAD-HVA patients offers a minimally invasive approach, reduced bleeding and lower radiation exposure compared with traditional free-hand surgery., Competing Interests: Declarations Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Vertebral arterial injury (VAI) remains a fatal complication of C1-C2 posterior screw fixation. Herein, we report asymptomatic bilateral VAI that was caused by screws following C1-C2 posterior fixation. A 34-year-old woman with cerebral palsy experienced quadriplegia after a fall. Cervical computed tomography (CT) showed increased ADI, with os odontoideum, for which C1 pedicle screw and C2 pedicle-lamina screw fixation were performed. Cervical magnetic resonance imaging (MRI) conducted for postoperative weakness in shoulder elevation demonstrated a well-decompressed spinal cord. However, neck CT angiography revealed bilateral vertebral artery (VA) violations by the C1 pedicle screw that induced occlusion of the V2 and V3 segments of both VA, with intact V4 segments. Diffusionweighted imaging showed no evidence of infarction. Cerebral angiography showed reconstitution of posterior circulation via the left fetal posterior communicating artery. Steroid treatment-induced improvement in shoulder elevation to the preoperative level, and no neurological deterioration has been detected for 3 years postoperatively. Prevention of VAI is one of the most important objectives when performing posterior cervical screw fixation. The screw should be inserted considering the rotation of C1 and C2. Notably, variations in cerebral circulation, which enable collateral blood flow to the posterior circulation, can lead to different sequelae in patients with iatrogenic VAI.

Objective: The study aimed to evaluate the safety, feasibility, effect on fusion, and clinical efficacy of atlas lateral mass and C2-3 transfacet screw fixation technique, serves as an alternative method to traditional posterior atlantoaxial fixation., Methods: Patients with atlantoaxial instability who underwent atlas lateral mass and C2-3 transfacet fixation surgery were included. The duration of the surgery and the quantity of blood lost during the operation were recorded. Patients were monitored via X-ray and computed tomography scans to evaluate the degree of fusion at the 1-month and 12-month follow-up. The Neck Visual Analog Scale and Neck Disability Index were evaluated preoperatively, in the postoperative first week, and at the 12-month follow-up for clinical follow-up., Results: A total of 8 patients with atlantoaxial instability due to odontoid fracture or Arnold- Chiari malformation accompanied by bony or vascular abnormalities were included in the study between 2017 and 2024. All 8 patients underwent successful atlas lateral mass and C2-3 transfacet screw fixation, with no neurovascular injury noted during surgery. All patients with fracture exhibited fusion at the 12-month mark, and both the Neck Visual Analog Scale and Neck Disability Index scores demonstrated significant improvement at both the 1-week and 12-month postoperative periods (P < 0.05)., Conclusions: The atlas lateral mass and C2-3 transfacet screw fixation technique, an alternative to conventional posterior fixation, has been demonstrated to be an efficacious method for providing adequate stabilization and fusion in patients with atlantoaxial instability, even in the cases of thin C2 pedicle, high-riding vertebral artery, previous failed surgeries, or reoperation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

A 61-year-old man was referred to our hospital for Stanford type A acute aortic dissection and an emergency operation was planned. In this case, the aberrant left vertebral artery originated directly from the aortic arch. Total arch replacement at the level between the left carotid artery and left aberrant vertebral artery was performed and an open stent graft was deployed in the true lumen of the descending aorta to obtain better distal aortic remodeling. The proximal edge of the nitinol skeleton of the open stent graft was placed distal to the orifice of the left subclavian artery. The left subclavian artery was not reconstructed in the mediastinum but bypassed distally to the left axillary artery so that the left subclavian artery could perfuse the aberrant left vertebral artery through the preserved aortic arch. Patency of all arch branches including the aberrant left vertebral artery was confirmed in postoperative computed tomography( CT) angiography.

Pediatric intracranial aneurysms (PIAs) are highly uncommon, with an incidence of <5% (0.17 to 4.6%) and <2% of PIA complicates into an aneurysmal hemorrhage. Pediatric aneurysms are usually treated by clipping, coiling, or more recently with flow diversion. Herein, we describe a 3-year male, whose ruptured vertebrobasilar junction aneurysm was successfully treated with a flow diverter and coiling., (Copyright © 2024 Neurology India, Neurological Society of India.)

Background and Importance: Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies., Clinical Presentation: An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion., Conclusion: This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background: Vertebral artery compression syndrome is a rare condition defined as the clinical presentation of dizziness, vertigo, ataxia, dysarthria, dysphagia, progressive or acute paralysis, hemisensory loss, and cervical myelopathy secondary to compression of the medulla and upper spinal cord by the vertebral artery., Case Description: Here we describe a 57-year-old Mexican-American male with bulbar symptoms, positional vertigo, and diplopia. The patient's symptoms were managed through microsurgical decompression of the medulla utilizing a far lateral transcondylar approach. The patient reported clinical improvement on follow-up., Conclusion: This case underscores the clinical complexity and heterogeneity of this rare neurovascular pathology and the importance of elucidating the pathophysiological mechanisms underlying the symptomatic presentation of vertebral artery compression syndrome., (© 2024. The Author(s).)

Objective: Penetrating cerebrovascular injuries (PCVI) are associated with a high incidence of mortality and neurological events. The optimal treatment strategy of PCVI, especially when damage control measures are required, remains controversial. The aim of this study was to describe the management of PCVI and patient outcomes at a level 1 trauma center where vascular injuries are managed predominantly by trauma surgeons., Methods: An institutional trauma registry was queried for patients with PCVI from 2011 to 2021. Patients with common carotid artery (CCA), internal carotid artery (ICA), or vertebral artery injuries were included for analysis. The primary outcome was in-hospital stroke. The secondary outcomes were in-hospital mortality and in-hospital stroke or death. A subgroup analysis was completed of arterial repair (primary repair or interposition graft) vs ligation or embolization vs temporary intravascular shunting at the index procedure., Results: We analyzed 54 patients with PCVI. Overall, the in-hospital stroke rate was 17% and in-hospital mortality was 26%. Twenty-one patients (39%) underwent arterial interventions for PCVI. Ten patients underwent arterial repair, six patients underwent ligation or embolization, and five patients underwent intravascular shunting as a damage control strategy with a plan for delayed repair. The rate of in-hospital stroke was 30% after arterial repair, 0% after arterial ligation or embolization, and 80% after temporary intravascular shunting. There was a significant difference in the stroke rate between the three subgroups (P = .015). Of the 32 patients who did not have an intervention to the CCA, ICA, or vertebral artery, 1 patient with ICA occlusion and 1 patient with CCA intimal injury developed in-hospital stroke. The mortality rate was 0% after arterial repair, 50% after ligation or embolization, and 60% after intravascular shunting. The rate of stroke or death was 30% in the arterial repair group, 50% in the ligation or embolization group, and 100% in the temporary intravascular shunting group., Conclusions: High rates of stroke and mortality were seen in patients requiring damage control after PCVI. In particular, temporary intravascular shunting was associated with a high incidence of in-hospital stroke and a 100% rate of stroke or death. Further investigation is needed into the factors related to these finding and whether the use of temporary intravascular shunting in PCVI is an advisable strategy., Competing Interests: Disclosures G.A.M. is a consultant for W. L. Gore & Associates and Silk Road Medical., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Vertebro-vertebral fistula involving the V3 segment of the vertebral artery is a rare vascular pathology which is either spontaneous or traumatic in origin. We describe a post-operative traumatic vertebro-vertebral fistula in a 47-year old lady with NF-1. We review reported cases of V3 segment vertebrovertebral fistula for their incidence, aetiology, clinical presentation, treatment and outcomes using an illustrative case. Traumatic V3 segment vertebrovertebral fistula is predominantly managed with parent vessel occlusion. Per the algorithm presented, we suggest endovascular management of non-traumatic fistula be based on the anatomical variance of the contralateral vertebral artery.

Background Context: A screw-rod system is the most widely used technique for atlantoaxial instability (AAI). However, neglecting anomalies of the vertebral artery and axis could lead to fatal complications. Whether or not the presence of AAI is associated with a more complicated anatomy for instrumentation is unclear.Purpose: To analyze the association between AAI and anomalies of the vertebral artery and axis in patients with and without AAI.Study Design: A retrospective comparative study.Patient Sample: One hundred and twenty patients who underwent preoperative 3-dimensional computed tomography with vertebral angiography of the cervical spine at our institution from 2012 to 2020.Outcome Measures: The C2 isthmus height, internal height of the C2 lateral mass, and C2 pedicle width were radiologically assessed.Methods: A case control study with matched cohort analysis was conducted. One hundred and twenty patients were divided into 2 groups according to presence of AAI, and the presence of high-riding vertebral artery (HRVA) and a narrow pedicle for insertion of the C2 pedicle screw was assessed, as was the prevalence of extraosseous vertebral artery anomaly.Results: The C2 isthmus height, C2 internal height, and C2 pedicle width were significantly narrower in the AAI group (p<.01, <.01, and <.01, respectively). A significantly greater proportion of patients with AAI had HRVA and a narrow pedicle than those without (p<.01 and < 0.01, respectively). Among patients with AAI, the C2 internal height was significantly narrower in patients with rheumatoid arthritis (p<.01). Five patients (8.3%) with AAI had vertebral artery anomaly (3 fenestration, 2 persistent first intersegmental artery), while there were no vertebral artery anomalies in patients without AAI (p<.01).Conclusions: Vertebral artery anomalies are more common in patients with AAI. Furthermore, posterior instrumentation in patients with AAI has a narrower safe zone compared to that in patients without AAI, which may be caused by a long-lasting deformity rather than a congenital deformity. Therefore, more thorough preoperative evaluation of the anatomy should be performed in these patients. [ABSTRACT FROM AUTHOR]

Cervical artery dissection is a common cause of stroke in young adults and can lead to significant disability. Clinicians should be able to recognize the clinical presentation and diagnose this condition to prevent cerebral ischemia and its complications. Consider cervical artery dissection in a young adult with new-onset, unilateral head pain with or without neck pain with antecedent neck trauma, with or without neurologic deficits or risk factors for dissection. Early diagnosis can lead to better outcomes but the overall prognosis is good for young adults with cervical artery dissection. [ABSTRACT FROM AUTHOR]

Introduction: Surgical treatment of hindbrain ischemia is becoming the accepted surgical procedure in cases of stenosis of extracranial segments of vertebral arteries in the course of advanced atherosclerotic lesions in their initial segments (V1) or caused by external compression of these arteries in the canal formed by the transverse processes of cervical vertebrae. The latter is referred to as vertebrobasilar insufficiency (VBI). The transposition of the left vertebral artery to the common carotid artery in cases where stent graft implantation is necessary with coverage of the subclavian artery and possible blood supply disorders of both the hindbrain and the spinal cord has become important. Material and methods: In the Department of Vascular Surgery at the Medical University in Wrocław, in 58 out of 76 patients treated for ischemia of the hindbrain, the procedures were performed in the distal vertebral artery. The authors present the diagnosis of 18 patients treated surgically for stenosis or kinking of vertebral arteries in their first segment. Results: In 12 cases, the procedure was performed with simultaneous unblocking of significantly narrowed left internal carotid artery. The material includes patients operated on between 1994 and 2018, most of whom had a good or very good outcome with zero mortality. Conclusions: Our results allow for a conclusion that proximal anastomosis of the common carotid and vertebral arteries is an effective method of treatment of vertebrobasilar insufficiency resulting both from atherosclerotic lesions of the vertebral arteries and their kinking. The qualification for the procedure is relatively difficult and must be based on angiography, whereas non-invasive methods are not fully reliable and should be, therefore, treated as auxiliary. We believe, however, that with increasing experience, ultrasound methods will also allow for a proper assessment. Unfavorable results of stenting, especially of vertebral arteries, demonstrated in our study, indicate the necessity to rely on surgical treatment. [ABSTRACT FROM AUTHOR]

Background and Purpose. The cause of in-stent restenosis (ISR) after vertebral artery ostium (VAO) stenting remains unclear. We evaluated factors associated with ISR in patients who underwent VAO stenting. We also assessed the feasibility of stenting for treating VAO stenosis (VAOS). Methods. Between January 2016 and October 2018, sixty-four consecutive patients who underwent a total of 66 stenting procedures were screened for symptomatic and asymptomatic atherosclerotic VAOS. Of these patients, 57 had complete follow-up data. The baseline patient demographics and morphological features of the VAO were recorded. Potential factors influencing ISR, including conventional cerebrovascular disease risk factors, were assessed, together with outcome events including recurrent transient ischemic attack (TIA), stroke, and vascular-related mortality. Results. The average follow-up period was 13.2 ± 4.6 months. Technical success was achieved in all interventions. The degree of stenosis was reduced from 77.2 ± 6.1 % to 13.7 ± 8.9 % after the procedure. ISR was detected in eight treated vessels (14.0%) and occlusion in two (5.3%) arteries. Of the 57 patients, one had an ischemic stroke and 5 had TIAs. The angle of the VAO at the subclavian artery was associated with the risk of restenosis (preoperative, P = 0.04 ; postoperative, P = 0.02). Conclusions. Stenting is a feasible and effective treatment for VAOS. The angle of the VAO at the subclavian artery may contribute to the development of ISR. [ABSTRACT FROM AUTHOR]