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Neurofibromatosis (NF1) is a relatively common multi-system genetic disorder. NF1 increases the risk of hypertension, and vasculopathy is a common finding. Extracranial vertebral artery aneurysm, though rare, can rupture and cause fatal hemorrhage. Pregnancy in NF1 is known to be associated with hypertension, preeclampsia, Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. We report anesthesia management of a primigravida with 30 weeks of gestation with neurofibromatosis presenting with severe preeclampsia and acute onset vertebral artery aneurysm, who underwent urgent cesarean section. We opted for general anesthesia over regional due to the risk of aneurysm rupture and technical difficulty with vigilant hemodynamic control. Postoperative course was complicated with HELLP and sepsis but was successfully managed. Knowledge, careful preoperative evaluation, appropriate technique, and management of anesthesia, and close postoperative monitoring are of utmost importance.

Background: Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms. Method: The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle. Conclusion: The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures. [ABSTRACT FROM AUTHOR]

BACKGROUND: The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications. METHODS: This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated. RESULTS: Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall. CONCLUSIONS: Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs.

Neurofibromatosis (NF1) is a relatively common multi-system genetic disorder. NF1 increases the risk of hypertension, and vasculopathy is a common finding. Extracranial vertebral artery aneurysm, though rare, can rupture and cause fatal hemorrhage. Pregnancy in NF1 is known to be associated with hypertension, preeclampsia, Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. We report anesthesia management of a primigravida with 30 weeks of gestation with neurofibromatosis presenting with severe preeclampsia and acute onset vertebral artery aneurysm, who underwent urgent cesarean section. We opted for general anesthesia over regional due to the risk of aneurysm rupture and technical difficulty with vigilant hemodynamic control. Postoperative course was complicated with HELLP and sepsis but was successfully managed. Knowledge, careful preoperative evaluation, appropriate technique, and management of anesthesia, and close postoperative monitoring are of utmost importance. [ABSTRACT FROM AUTHOR]

Background: In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes. Methods: Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated. Results: Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA–PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively. Conclusions: Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.

Pipeline embolization device (PED) deployment is a technically demanding procedure. Incomplete device expansion or deployment is one intra-operative risk, especially in patients with significant vascular tortuosity. We describe the case of a 71-year female with an unruptured left vertebral artery saccular aneurysm. Tortuosity of the arteries proximal to the aneurysm complicated deployment and the proximal end of the PED failed to expand despite several maneuvers. The inadequately expanded PED caused flow limitation in the left vertebral artery and it became imperative to achieve wall apposition of the PED. We salvaged the PED from the left vertebral artery by retrograde trans-right posterior communicating artery balloon angioplasty. Our case documents the successful application of the rarely used salvage strategy – anterior-to-posterior circulation retrograde rescue balloon angioplasty of an unopened PED. [ABSTRACT FROM AUTHOR]

Background: Vertebral artery (VA) aneurysm is a rare etiology of cervical radiculopathy and there is a paucity of case reports described in the literature. Case Description: We describe a case of a patient with no history of trauma presenting with a large right VA aneurysm at the C5-C6 level compressing the C6 nerve root and causing a painful radiculopathy. The patient underwent successful external carotid artery-radial artery-VA bypass followed by trapping of the aneurysm and decompression of the C6 nerve root. Conclusion: VA bypass is an effective tool for treatment of symptomatic large extracranial VA aneurysms and a rare cause of radiculopathy. [ABSTRACT FROM AUTHOR]

ABSTRACT: Takayasu arteritis (TA) is a common autoimmune disease in the clinical setting. However, vertebral artery aneurysms caused by TA are rarely reported. We herein describe a 28-year-old man with multiple vertebral artery aneurysms and carotid artery aneurysms caused by TA, which showed typical wall thickening and lumen dilation with a “string of beads” appearance by Doppler ultrasound and radiology. Previous studies have shown that most TA-associated vertebral artery lesions are stenosis, occlusion, and dissection of the intracranial part of the artery. In this case, TA mainly affected the cervical segment of the vertebral artery (the intracranial segment was not obviously involved), and the main manifestations were aneurysms and occlusion. This case provides more information for further understanding of TA-associated vertebral artery lesions.

Objective To evaluate the effect of surgical treatment on extracranial supra-aortic aneurysms and summarize the experience. Methods The clinical data of 10 patients undergoing surgical treatment of extracranial supra-aortic aneurysms from May 2019 to November 2023 in the Department of Vascular Surgery of Beijing Tiantan Hospital affiliated to Capital Medical University were collected.The 10 patients included 5 patients with internal carotid artery aneurysm,2 patients with subclavian artery aneurysm,2 patients with vertebral artery aneurysm,and 1 patient with internal carotid artery aneurysm combined with ipsilateral subclavian artery aneurysm.The surgical indications,surgical regimens,clinical efficacy,and complications were retrospectively analyzed. Results All the 10 patients underwent surgery successfully,with the surgery duration range of 60-420 min and the median surgery duration of 180.0 (121.5,307.5) min.Intraoperative bleeding volume varied within 30-400 mL,with a median of 90 (50,125) mL.The time of carotid artery blocking and vertebral artery blocking varied within the ranges of 10-20 min and 20-30 min,with the medians of 15.0 (11.5,16.3) min and 25.0 (15.0,22.5) min,respectively.No cardiac accident,cerebral infarction,or cerebral hemorrhage occurred during the perioperative period.The 10 patients were followed up for 3-58 months,with the median follow-up time of 8.5 (5.3,17.0) months.One patient with subclavian artery aneurysm developed artificial vessel occlusion 20 months after surgery.One patient with internal carotid artery aneurysm developed distal carotid artery stenosis 6 months after surgery. Conclusion Surgical treatment should be actively adopted for extracranial supra-aortic aneurysms,and individualized surgical regimens should be designed according to patient conditions.

The vertebrobasilar system is made up of the two vertebral arteries that unite to form the basilar artery near the base of the skull. Aneurysms in the vertebrobasilar system are distinct from other cerebral aneurysms due to their unique morphologic characteristics. They can be large and bulging (massive), pressing on the brainstem. Alternatively, they might be weak and splitting apart (dissecting) or have an elongated shape (fusiform). On the other end of the spectrum, Vertebral artery aneurysms (VAAs) can also be small and rounded (saccular). These aneurysms can occur at the vertebral artery itself or where it joins the posterior inferior cerebellar artery (PICA). Anatomically, they are situated near the brainstem and cranial nerves, deep within the posterior fossa. The cerebrospinal fluid is kept in transit and flux by the ventricular system's chambers circulating the fluid within themselves. An intraventricular hemorrhage (IVH) can occasionally result from vertebral artery aneurysmal ruptures that result in bleeding into the subarachnoid space and then extravasate into the ventricles. Persistent and poorly controlled hypertension affects about 50% of individuals with IVH. In this case report, we study a 74-year-old woman who complained of a sudden onset headache that had been bothering her for three days at the medical emergency room. She had been diagnosed with systemic hypertension eight years prior and had not taken her medicines as prescribed. She was discovered to have rigidity in her neck and a blood pressure reading of 170/100 mmHg, which had been followed by an episode of vomiting. Radiological investigations revealed a VAA that had a high risk of rupturing and causing an IVH., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Chavhan et al.)

Background: Morphological changes of a stented artery can cause a flow diversion effect to reduce intra-aneurysmal flow; however, there is a potential for the negative effect of increased intra-aneurysmal flow. We present cases with multiple overlapping stents for a partially thrombosed vertebral artery aneurysm and characterize the hemodynamic properties of a recurrent case by focusing on the morphological changes of the stented artery.Methods: Between October 2017 and April 2019, four consecutive cases of symptomatic unruptured large and giant partially thrombosed vertebral artery aneurysms were treated with multiple overlapping low-profile visualized intraluminal support stents and no coils. Both angiographic and clinical outcomes were assessed. Computational fluid dynamics analysis was performed to clarify hemodynamic features. The degree of pressure elevation was calculated as the pressure difference (Pd). Wall shear stress (WSS) was also calculated.Results: In three of the four cases, successful flow reduction was achieved with no morphological change of the stented arteries. The patients' symptoms were gradually improved. The remaining case required additional stents after the initial treatment. In the recurrent case, Pd was noticeably elevated at the aneurysm neck after treatment, and WSS was generally increased in the area due to altered blood flow into the aneurysm dome caused by morphological changes of the stented artery.Conclusion: Overlapping stents can be used for the treatment of large and giant thrombosed vertebral artery aneurysms with flow diversion effect; however, morphological changes of the stented artery requires careful attention as it may lead to an increase in the intra-aneurysmal flow, causing negative outcomes.

Abstract Background Case description Conclusion 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.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.MVD is an effective treatment for HFS caused by a fusiform VA aneurysm because symptoms are likely to improve immediately after treatment. [ABSTRACT FROM AUTHOR]

Background: Morphological changes of a stented artery can cause a flow diversion effect to reduce intra-aneurysmal flow; however, there is a potential for the negative effect of increased intra-aneurysmal flow. We present cases with multiple overlapping stents for a partially thrombosed vertebral artery aneurysm and characterize the hemodynamic properties of a recurrent case by focusing on the morphological changes of the stented artery. Methods: Between October 2017 and April 2019, four consecutive cases of symptomatic unruptured large and giant partially thrombosed vertebral artery aneurysms were treated with multiple overlapping low-profile visualized intraluminal support stents and no coils. Both angiographic and clinical outcomes were assessed. Computational fluid dynamics analysis was performed to clarify hemodynamic features. The degree of pressure elevation was calculated as the pressure difference (Pd). Wall shear stress (WSS) was also calculated. Results: In three of the four cases, successful flow reduction was achieved with no morphological change of the stented arteries. The patients' symptoms were gradually improved. The remaining case required additional stents after the initial treatment. In the recurrent case, Pd was noticeably elevated at the aneurysm neck after treatment, and WSS was generally increased in the area due to altered blood flow into the aneurysm dome caused by morphological changes of the stented artery. Conclusion: Overlapping stents can be used for the treatment of large and giant thrombosed vertebral artery aneurysms with flow diversion effect; however, morphological changes of the stented artery requires careful attention as it may lead to an increase in the intra-aneurysmal flow, causing negative outcomes. [ABSTRACT FROM AUTHOR]

Unclippable vertebral artery aneurysms (UVAs) are difficult to treat with direct clipping, especially in cases involving the origin of the posterior inferior cerebellar artery (PICA). Bypass with trapping is the common procedure used for these conditions. The authors used the blind-alley formation technique, which is a simpler method than trapping and can avoid some complications. To report 7 cases of UVA with PICA involvement treated with blind-alley formation and occipital artery (OA)-PICA bypass as well as their surgical outcomes and complications and to describe the operative techniques. Seven patients with UVA and PICA involvement underwent OA-PICA bypass and blind-alley formation (occlusions of the PICA origin and vertebral artery proximal to the aneurysm). Vertebral artery dissecting aneurysms and fusiform atherosclerotic vertebral artery aneurysms were detected in 6 patients and 1 patient, respectively. All patients presented with subarachnoid hemorrhage, and 71.4% of them were classified into the poor-grade group. Good bypass patency and complete aneurysm obliteration were achieved in all cases. Six aneurysms (85.7%) were completely obliterated according to computed tomography angiography performed immediately postoperatively. Another aneurysm was 50% and 100% thrombosed immediately and at 7 days after the operation, respectively. Surgical complications were found in 1 patient (14.3%) who had postoperative diparesis with dysphagia. Three patients (42.9%) achieved a Glasgow Outcome Score of 4 or 5 one month after the operation. Blind-alley formation and OA-PICA bypass are simple, safe, and effective for the treatment of patients with UVA with PICA involvement. [ABSTRACT FROM AUTHOR]

Object: The pipeline embolization device (PED) has been used to treat non-saccular, unruptured, intradural vertebral artery aneurysms at some institutions. However, there is an absence of large controlled studies validating the feasibility of this treatment. This study aimed to explore the therapeutic feasibility of PED by comparing PED treatment with controlled stent-assisted coiling (SAC).Materials and Methods: Thirty-two PED procedures were matched in a 1:2 manner with 64 SAC procedures based on patient age, sex, aneurysm size, and aneurysm location. Technical factors, procedural complications, angiographic results, and clinical outcomes were analyzed and compared.Results: There was no statistically significant difference in technical factors and procedural complications between the two groups (PED vs. SAC, 9.4 vs. 4.7%, P = 0.397). In multivariate analysis, smoking and therapeutic modality were identified as independent predictors of occlusion. Smoking was a risk factor for aneurysm obliteration [hazard ratio (HR) 0.53; 95% confidence interval (CI), 0.31–0.89; P = 0.018]. Aneurysms treated with PED were more likely to achieve obliteration over time compared with aneurysms treated with SAC (HR 2.97; 95% CI, 1.79–4.93; P < 0.001). The rate of favorable clinical outcomes (modified Rankin Scale (mRS), 0–2) was similar between the two groups (PED vs. SAC, 100 vs. 96.9%, P = 0.551). In the SAC group, one patient had neurological deficit with an mRS of four at the latest follow-up. There was no mortality in either group.Conclusions: The PED and SAC groups showed similar technical factors, procedural complications, angiographic results, and favorable clinical outcomes. Aneurysms treated with PED were more prone to obliteration over time than aneurysms treated with SAC. These outcomes suggest, based on short-term follow-up, PED is a safe and feasible strategy for the treatment of non-saccular, unruptured, intradural vertebral artery aneurysms.

Background: The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications., Methods: This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated., Results: Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall., Conclusions: Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

This article reports a patient with unruptured right vertebral artery aneurysm which deviates across the midline to the left side. The contralateral (left) transcondylar fossa approach with bilateral V3 exposure is used for aneurysm clipping. The literature related to this technique is also reviewed. [ABSTRACT FROM AUTHOR]

Object: The pipeline embolization device (PED) has been used to treat non-saccular, unruptured, intradural vertebral artery aneurysms at some institutions. However, there is an absence of large controlled studies validating the feasibility of this treatment. This study aimed to explore the therapeutic feasibility of PED by comparing PED treatment with controlled stent-assisted coiling (SAC). Materials and Methods: Thirty-two PED procedures were matched in a 1:2 manner with 64 SAC procedures based on patient age, sex, aneurysm size, and aneurysm location. Technical factors, procedural complications, angiographic results, and clinical outcomes were analyzed and compared. Results: There was no statistically significant difference in technical factors and procedural complications between the two groups (PED vs. SAC, 9.4 vs. 4.7%, P = 0.397). In multivariate analysis, smoking and therapeutic modality were identified as independent predictors of occlusion. Smoking was a risk factor for aneurysm obliteration [hazard ratio (HR) 0.53; 95% confidence interval (CI), 0.31–0.89; P = 0.018]. Aneurysms treated with PED were more likely to achieve obliteration over time compared with aneurysms treated with SAC (HR 2.97; 95% CI, 1.79–4.93; P < 0.001). The rate of favorable clinical outcomes (modified Rankin Scale (mRS), 0–2) was similar between the two groups (PED vs. SAC, 100 vs. 96.9%, P = 0.551). In the SAC group, one patient had neurological deficit with an mRS of four at the latest follow-up. There was no mortality in either group. Conclusions: The PED and SAC groups showed similar technical factors, procedural complications, angiographic results, and favorable clinical outcomes. Aneurysms treated with PED were more prone to obliteration over time than aneurysms treated with SAC. These outcomes suggest, based on short-term follow-up, PED is a safe and feasible strategy for the treatment of non-saccular, unruptured, intradural vertebral artery aneurysms. [ABSTRACT FROM AUTHOR]

Background and Aims: Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; various surgical and endovascular treatment options are available. Methods: We report a 44-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. The patient presented with brainstem infarction, and the diagnosis of primary extracranial vertebral artery aneurysm was made by computed tomography angiography (CTA). Results: This patient's aneurysm was definitively treated using an endovascular approach with placement of a covered stent in the right proximal vertebral artery. Conclusion: Although aneurysms of this location are traditionally repaired with open aneurysmectomy, we show that endovascular treatment can be a safe and effective alternative approach. In the case reported here, primary extracranial vertebral artery aneurysm presenting with embolic stroke was successfully treated with a covered stent. Complete exclusion of the aneurysm from blood circulation is advisable to achieve full resolution of the embolic source. [ABSTRACT FROM AUTHOR]

Introduction Complex skull base approaches are frequently used to treat intracranial vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) aneurysms. These complex procedures are associated with higher risk of neurovascular injury. Hence, a less-invasive surgical approach is needed to improve the efficacy and safety of treatment. Methods A retrospective analysis was conducted on clinical and radiologic data from surgeries in which simple lateral suboccipital and “lateral-enough” approaches were used to clip VA aneurysms in the Department of Neurosurgery at Helsinki University Central Hospital from 2000 to 2009. Results Fifty-two VA or PICA aneurysms were treated using the simple lateral suboccipital approach. Sixteen patients (31%) presented with an unruptured aneurysm, 21 patients (40%) with World Federation of Neurosurgical Societies (WFNS) grade 1–3, and 15 patients (29%) with World Federation of Neurosurgical Societies grade 4–5. The aneurysms were saccular in 48 cases (92%), dissecting in 3 cases (6%), and fusiform in 1 case (2%). The most common aneurysm location was the VA-PICA junction (81%). The mean final modified Rankin Scale score was 2, and in unruptured cases, all patients had favorable clinical outcomes. The main causes of unfavorable outcome were poor preoperative clinical grade ( P = 0.002), preoperative intraventricular hemorrhage ( P = 0.008), postoperative hydrocephalus ( P = 0.003), brain infarction ( P = 0.005), and postoperative pneumonia ( P < 0.001). Conclusions We describe a 10-year experience using a simple lateral suboccipital approach and its modification by the senior author (J.H.) to treat VA and proximal PICA aneurysms. Unfavorable outcome was related to the poor preoperative clinical grade, preoperative intraventricular hemorrhage, and postoperative pneumonia. [ABSTRACT FROM AUTHOR]

Vertebral artery compressing the medulla and causing intractable vomiting has only been reported once previously. We report a case of a 69-year-old woman with intractable nausea and vomiting causing a 50 pound weight loss and who failed medical management and whose symptoms were completely reversed following microvascular decompression (MVD).

Background: In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes., Methods: Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated., Results: Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA-PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively., Conclusions: Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background An anomalous vertebral artery is not a deterrent for posterior C1-C2 joint manipulation and reduction of atlantoaxial dislocation (AAD). However, presence of an incidental aneurysm in the aberrant segment of artery with concurrent AAD adds to the surgical challenge. Case description A 30-year-old woman presented with neck pain and spastic quadriparesis. Her imaging revealed atlantoaxial dislocation and bony segmentation defects. Three-dimensional computed tomography angiography showed bilateral anomalous vertebral arteries (V3 segment) and an incidental aneurysm on the arterial segment that crossed the right C1-C2 joint posteriorly. Because the artery bearing the aneurysm was nondominant, it was ligated and successful C1-C2 posterior reduction and fusion could be performed. Conclusion The association of an incidental aneurysm with an anomalous vertebral artery in congenital AAD is unusual. The etiology could be an underlying collagen defect or repeated shearing trauma to the vessel wall due to C1-C2 instability. It would be less risky to proceed with endovascular embolization followed by occipitocervical fusion without opening the joints in case the aneurysm is present on the dominant aberrant V3 segment. Ventral decompression can be supplemented for irreducible AAD. On the contrary, if the aneurysm is present on the nondominant aberrant V3 segment, the C1-2 joint can be opened and manipulated following an initial endovascular treatment of the aneurysm. If the circumstances demand, the nondominant artery can be ligated and sacrificed, although there is a small risk of formation of stump aneurysm. Highlights • Congenital atlantoaxial dislocation with concurrent anomalous artery bearing an aneurysm is rare. • The etiology is plausibly underlying collagen defects or tears due to repeated shear secondary to instability. • The vertebral artery bearing the aneurysm can be sacrificed if nondominant while manipulating the joint. • Endovascular coiling followed by stabilization without joint manipulation is preferable with aneurysm on dominant VA. [ABSTRACT FROM AUTHOR]

Neurofibromatosis 1 is an autosomal dominant disorder characterized by cafe-au-lait spots, cutaneous neurofibroma, and bony deformities. Vascular abnormality such as stenosis, aneurysm, or rupture associated with neurofibromatosis 1 is rare. Rupture of vertebral artery aneurysm into the thoracic cavity is extremely rare. The outcomes of patients with aneurysmal ruptures are very poor when spontaneous hemothorax occur. A 31-year-old woman presented to the emergency department with left shoulder pain and with both lower chest wall pain and left supraclavicular area swelling. The chest computed tomography scan revealed about 4-cm pseudo-aneurysm probable arising from the left vertebral artery with large hematoma at left supraclavicular area. Neurofibromatosis 1 is generally being regarded as a benign disease but has the potential for serious vascular complications. When aneurysms were ruptured, cervical hematoma, hemothorax, or hypotension was developed. It is potentially a life-threatening condition, so it must require emergent management. Emergency physicians must remember the relation of neurofibromatosis 1 and serious vascular complications and ensure rapid access to rule out vascular lesions, so as to prevent the life-threatening condition. [ABSTRACT FROM AUTHOR]

Pseudoaneurysms of the extracranial vertebral artery are extremely rare due to their deep location and the anatomical protection of this artery. They can be caused by cervical traumas (firearm injuries, sports, hyperextension of the neck and iatrogeny). The authors report the case of a patient who developed a giant pseudoaneurysm of the extracranial vertebral artery after surgery for the removal of a tumor of the cerebellopontine angle in which surgical lesion of the artery occurred. Treatment was performed by endovascular approach. Literature is reviewed and comments are made on the physiopathogeny of the lesion and the different forms of treatment.Os pseudoaneurismas da artéria vertebral extracraniana são extremamente raros pela localização profunda e proteção anatômica desta artéria. Podem ser ocasionados por traumas cervicais (ferimentos por armas de fogo, esportes, hiperextensão do pescoço e iãtrogenias). Os autores relatam o caso de um paciente que desenvolveu um pseudoaneurisma gigante da artéria vertebral extracraniana após cirurgia para retirada de tumor de ângulo ponto cerebelar em que ocorreu a lesão cirúrgica desta artéria e cujo tratamento foi endovascular. A literatura é revisada e são feitas considerações sobre a fisiopatogenia da lesão e as várias formas de tratamento.

Cerebrovascular complications are seen in <10% of the patients with Takayasu arteritis (TA). Subarachnoid hemorrhage and cerebral aneurysms in TA are exceedingly rare, and have been documented as case reports in the literature. We present the case of a 38-year-old lady who presented with subarachnoid hemorrhage to the emergency room. Clinical and radiologic evaluation documented that she had TA. Her digital subtraction angiogram revealed complete occlusion of the bilateral common carotid arteries and left subclavian artery at their origins. The right subclavian artery was completely occluded after the origin of the right vertebral artery. The right vertebral artery was dilated, and was the only vessel supplying the entire intracranial circulation. She harbored an aneurysm at the right vertebral artery-posterior inferior cerebrally artery (VA-PICA) junction, measuring 9.5×11.7 mm in size, with neck measuring 8.6 mm. She underwent retromastoid craniectomy and microsurgical clipping of the aneurysm, with no major complications. To the best of our knowledge, only 1 case had been reported earlier in the literature so far, with a single vessel supplying the whole intracranial circulation, who was conservatively managed. We report the first case of successful surgical management of a rare case of vertebral artery aneurysm in the only patent vessel supplying the whole intracranial circulation and both upper limbs. [ABSTRACT FROM AUTHOR]