[Microsurgery for Vertebral and Posterior Inferior Cerebellar Artery Aneurysms via Lateral Suboccipital Craniotomy].

Among ruptured intracranial aneurysms, aneurysms of the vertebral artery(VA) and posterior inferior cerebellar artery(PICA) are relatively rare, and they exhibit distinct characteristics. These include: 1) a high frequency of diverse aneurysmal morphologies, such as fusiform or dissecting aneurysms; 2) proximity to the lower cranial nerves; 3) the presence of perforators to the medulla oblongata; and, 4) obstruction to the surgical approach by specific bony structures, such as the occipital condyle and jugular tubercle. Consequently, these aneurysms often require interventions that are more complex than simple clipping or coiling, which is typical for anterior circulation aneurysms. Interventions include skull base techniques such as the far-lateral approach and revascularization procedures such as occipital artery(OA)-PICA bypass. Despite these complexities, the rarity of these aneurysms and the recent advancements in endovascular procedures pose challenges for young neurosurgeons in acquiring adequate microsurgical experience. This narrative review addresses the clinical features of VA and PICA aneurysms, the history and variations in the lateral suboccipital approach for these aneurysms, and several bypass techniques for reconstructing the PICA. Lastly, we illustrate our current microsurgical practices through a case presentation accompanied by a surgical video showcasing both the far-lateral approach and the OA-PICA bypass.

Single-branched stent-graft with on-table fenestration for the management of zone 2 landing TEVAR with an isolated left vertebral artery: a pilot study.

BACKGROUND: It is challenging to simultaneously conduct total endovascular repair and reconstruct the left subclavian artery (LSA) and isolated left vertebral artery (ILVA) in patients who had an ILVA and required zone 2 anchoring. This pilot study reported the initial application experience of thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing for aortic arch reconstruction in patients with ILVA. METHODS: This study was a retrospective consecutive single-center case series analysis, which involved four patients with ILVA who required zone 2 anchoring and received TEVAR combined with a single-branched stent graft and concomitant on-table fenestration between March 2021 and December 2022. RESULTS: The postoperative follow-up period was 6-27 months, and no postoperative deaths or other primary complications occurred. There were no signs of a stroke or spinal cord ischemia, as well as no chest or back pain. The postoperative computed tomography angiography showed unobstructed ILVA and LSA, no stent stenosis and displacement, and no signs of endoleak. CONCLUSION: The outcome suggested that this technique might be a feasible, safe, and alternative treatment for such patients. Further studies with larger samples and longer follow-up periods are needed to confirm our findings.

A screw algorithm for congenital C2-3 fusion with high-riding vertebral arteries: feasibilities and clinical outcomes of five different fixation techniques.

OBJECTIVE: To propose a screw algorithm and investigate the anatomical feasibilities and clinical outcomes of five distinct fixation methods for C2-3 fused vertebra with high-ridding vertebral arteries (VA) (HRVA) when the C2 pedicle screw placement is unfeasible. METHODS: Thirty surgical patients with congenital C2-3 fusion, HRVA, and atlantoaxial dislocation (AAD) were included. We designed a algorithm for alternative screw implantation into C2-3 fused vertebrae, including C2 pedicle screw with in-out-in (passing VA groove) technique (in-out-in screw), subfacetal screw, translaminar screw, lateral mass screw, C3 pedicle screw. VA diameter and position, C2 and C3 pedicles, superior facets, fused lamina, and fused lateral mass dimensions were evaluated for screw implantation indication. Implant failure, reduction loss, implant placement accuracy were investigated by computed tomography. RESULTS: A total of 5 VAs were identified as distant VAs; a total of 2 VAs were categorized as occlusive VAs. Sufficient dimension of lateral mass and lamina provided the broadest indications for screw implantation, while the distant or occlusive VA provided the most limited indications for in-out-in screw. The indications of five alternative methods ranged from narrowest to widest as follows: in-out-in screw, C3 pedicle screw, subfacetal screw, translaminar screw, lateral mass screw. The translaminar screws and the lateral mass screws increased the probability of implant failure. All patients who received in-out-in screws, C3 pedicle screws, and subfacetal screws achieved fusion. The accuracy ranged from lowest to highest as follows: C3 pedicle screw, lateral mass screw, in-out-in screw, subfacetal screw, translaminar screw. No translaminar screws deviated. CONCLUSIONS: The algorithm proved to be a valuable tool for screw selection in cases of C2-3 fused vertebrae with HRVAs. The subfacetal screw, boasting broad indications, a high fusion rate, and exceptional accuracy, stood as the primary preferred alternative.

[Curative effect analysis of anterior cervical discectomy and fusion in patients with cervical spondylosis of vertebral artery type].

OBJECTIVE: To investigate the clinical effect of anterior cervical discectomy and fusion (ACDF) in the treatment of cervical spondylosis of vertebral artery type(CSA). METHODS: The clinical data of 42 patients with CSA from January 2020 to January 2022 were retrospectively analyzed. There were 25 males and 17 females, aged from 30 to 74 years old with an average of (53.9±11.0) years old. There were 18 cases with single-segment lesions, 17 cases with two-segment lesions, and 7 cases with three-segment lesions. The American Academy of Otolaryngology-Head and Neck Surgery's Hearing and Balance Committee score (CHE), the Neck Disability Index (NDI) and the cervical curvature Cobb angle were recorded before surgery and after surgery at 6 months. RESULTS: All 42 ACDF patients were followed up for 6 to 30 months with an average of (14.0±5.2) months. The operative time ranged from 95 to 220 min with an average of (160.38±36.77) min, the intraoperative blood loss ranged from 30 to 85 ml with an average of (53.60±18.98) ml. Tow patients had mild postoperative dysphagia, which improved with symptomatic treatment such as nebulized inhalation. CHE score decreased from (4.05±0.96) preoperatively to (2.40±0.70) at 6 months postoperatively (t=12.97, P<0.05). The number of improved vertigo at 6 months postoperatively was 38, with an improvement rate of 90.5%. NDI score was reduced from (34.43±8.04) preoperatively to (20.76±3.91) at 6 months postoperatively (t=11.83, P<0.05). The cervical curvature Cobb angle improved from (8.04±6.70)° preoperatively to (12.42±5.23)° at 6 months postoperatively (t=-15.96, P<0.05). CONCLUSION: The ACDF procedure has outstanding clinical efficacy in treating CSA. The operation can rapidly relieve patients' episodic vertigo symptoms by relieving bony compression and reconstructing cervical curvature. However, it is necessary to strictly grasp the indications for surgery and clarify the causes of vertigo in patients, and ACDF surgery is recommended for CSA patients for whom conservative treatment is ineffective.

Cervical intraosseous arteriovenous malformation: report of a rare entity and its management dilemmas.

Intraosseous occurrence of a spinal AVM is anecdotal, with only four such cases reported previously. This is the first report of a spinal intraosseous AVM in the cervical vertebrae. A 44-year-old male patient presented with a 2-month history of progressive quadriparesis and bladder dysfunction. Magnetic resonance imaging showed multiple flow voids within the C4 and C5 vertebral bodies, and an extradural component causing cord compression. CT showed extensive bony destruction at both levels. The diagnosis of an intraosseous AVM was confirmed with spinal angiography. The AVM was noted to be fed by branches from the ascending cervical arteries and the vertebral artery. The nidus was draining into the vertebral venous plexus and thence into the jugular vein through the marginal sinus. The patient underwent partial embolization of the AVM. Surgical resection was attempted but found to be unfeasible due to torrential bleeding. A 360-degree stabilization along with decompressive laminectomies was performed, resulting in clinical improvement and disease stabilization at one year follow-up. The case and its management dilemmas are discussed in light of a brief literature review.

Transradial and Transfemoral Approaches for Vertebral Artery Stenting: A Single-Center, Prospective, Non-Inferiority Comparison.

BACKGROUND Vertebral artery origin stenosis (VAOS) has recently gained increased attention, with endovascular treatments like stent implantation showing high success and low complication rates, although less is known about VAOS compared to carotid artery stenosis. This study evaluated the safety and effectiveness of transradial (TRA) and transfemoral (TFA) approaches for VAOS stent placement. MATERIAL AND METHODS We recruited a total of 102 patients undergoing vertebral artery stenting in our hospital between January 2020 and November 2022. Patients were randomly assigned to undergo either radial or femoral approach for stent implantation in the vertebral artery, and the radial approach group secondary divided into 2 groups by patients' consent: ipsilateral or contralateral radial approach. The success rates of VAOS stent implantation, operation time, and postoperative hospitalization time were compared between the 3 groups. In addition, we compared the outcomes of stroke within 30 days, transient ischemic attack (TIA) within 30 days, and other indicators. RESULTS Of the 102 patients, the final success rate of stent implantation was not significantly different between the 3 groups. The time from sheath insertion to stent insertion in the ipsilateral TRA group (median time: 19 min [interquartile range (IQR): 12-24.5 min]) was significantly shorter than in the transfemoral approach (TFA) group (median time: 29 min [IQR: 21-35.5 min]) (P<0.01; 95% confidence interval (95% CI): 10 min [6-14 min]). There were no statistically significant differences between the 3 groups in terms of cerebrovascular events within 1 month, and patient satisfaction and preference favored the radial approach. CONCLUSIONS The postoperative hospitalization time and operation time associated with the ipsilateral TRA were shorter, and patient acceptance and satisfaction were higher.

Indications, operative techniques, and outcomes of occipital artery-vertebral artery bypass: an institutional series.

PURPOSE: Posterior circulation cerebral bypasses often show higher risks and lower patency. Only few reports discussed occipital artery (OA)-vertebral artery (VA) bypasses. We present our illustrative cases to address current gaps in the literature on OA-VA bypass. METHODS: A single-center retrospective review was conducted to include all institutional cases of OA-VA bypass, discussing the technique and outcomes. RESULTS: Four institutional cases undergoing a total of 5 bypasses were evaluated, including 3 males and 1 female, with median age of 65 years (range, 62-73). All patients had vertebrobasilar insufficiency (VBI) with recurrent strokes/TIAs due to intracranial atherosclerosis, leading to unilateral VA stenosis with contralateral occlusion (1, 25%), bilateral VA stenosis (1, 25%) or occlusion (1, 25%). Medical management included aspirin for all cases (100%), with clopidogrel in 3 (75%). Surgery was performed through a far lateral approach, connecting the OA to the VA-3 segment, with no inter-positional graft. One patient underwent contralateral OA-VA bypass 6 months after the prior surgery due to worsening of the contralateral VA stenosis. Bypass patency was confirmed in all cases with post-operative angiography. All patients had clinical improvement, with one case of wound dehiscence managed conservatively. All patients were alive at last follow-up (median 7.0 months; range: 1.5-18). CONCLUSION: OA-VA bypass is a challenging yet effective strategy in selected patients with VBI. Current literature lacks unique definitions of surgical indications and techniques, which we addressed in our series. Surgical education should focus on expanding the microsurgery anatomy knowledge.

[Single Center Experience in Surgical Treatment of Extracranial Supra-Aortic Aneurysms].

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 impact of an anomalous third segment of the vertebral artery on bypass surgery: a case report and literature review.

The horizontal part of the third segment (V3) of the vertebral artery (VA) is a critical anastomotic site for bypass procedures involving either donor or recipient vessels. It is rare for the V3 segment to deviate from its typical course of passing through the atlanto-transverse foramen. V3 anomaly encountered in occipital artery (OA)-V3 bypass surgery has not been previously reported. Here, we present a case involving a patient undergoing bypass surgery due to recurrent post-stent occlusion at the first segment (V1) of the left VA. During the operation, it was noted that the V3 horizontal segment could not be identified within the left VA groove, leading to initial suspicion of left V3 disuse atrophy attributed to prolonged chronic ischaemia. Consequently, there was a need to modify the operative method and to transition from an OA-V3 bypass to an OA-posterior inferior cerebellar artery bypass. Post-operative computed tomography angiography confirmed that indeed, the left V3 did not traverse through the transverse foramen of the atlas and instead entered the dural membrane between the first cervical vertebra (C1) and the second cervical vertebra (C2).

Cerebral Ischemic Coma Model Induced by Modified Four-Vessel Occlusion.

Coma caused by cerebral ischemia is the most serious complication of cerebral ischemia. Four-vessel occlusion can establish a cerebral ischemic coma model for disease research and drug development. However, the commonly used four-vessel occlusion method mainly involves inserting an electrocoagulation pen into the bilateral pterygoid foramen of the first cervical vertebra behind the neck to electrocoagulate the vertebral arteries. This process carries the risk of incomplete electrocoagulation, bleeding, and damage to the brainstem and spinal cord. Twenty-four hours after surgery, re-anesthetized rats undergo carotid artery ligation in front of the neck. Two surgeries expose the rats to a higher risk of infection and increase the experimental period. In this study, during a single surgical procedure, an anterior cervical incision was used to locate the key site where the vertebral artery penetrates the first cervical vertebra. The bilateral vertebral arteries were electrocauterized under visual conditions, while the bilateral common carotid arteries were separated to place loose knots. When the rats showed consciousness of the inversion reaction, the bilateral common carotid arteries were quickly ligated to induce ischemic coma. This method can avoid the risk of infection caused by two surgical operations and is easy to perform with a high success rate, providing a useful reference for relevant practitioners.

Association between cervicocerebral artery dissection and tortuosity - a review on quantitative and qualitative assessment.

Cervicocerebral artery dissection stands out as a significant contributor to ischemic stroke in young adults. Several studies have shown that arterial tortuosity is associated with dissection. We searched Pubmed and Embase to identify studies on the association between arterial tortuosity and cervicocerebral artery dissection, and to perform a review on the epidemiology of cervicocerebral artery tortuosity and dissection, pathophysiology, measurement of vessels tortuosity, strength of association between tortuosity and dissection, clinical manifestation and management strategies. The prevalence of tortuosity in dissected cervical arteries was reported to be around 22%-65% while it is only around 8%-22% in non-dissected arteries. In tortuous cervical arteries elastin and tunica media degradation, increased wall stiffness, changes in hemodynamics as well as arterial wall inflammation might be associated with dissection. Arterial tortuosity index and vertebrobasilar artery deviation is used to measure the level of vessel tortuosity. Studies have shown an independent association between these two measurements and cervicocerebral artery dissection. Different anatomical variants of tortuosity such as loops, coils and kinks may have a different level of association with cervicocerebral artery dissection. Symptomatic patients with extracranial cervical artery dissection are often treated with anticoagulant or antiplatelet agents, while patients with intracranial arterial dissection were often treated with antiplatelets only due to concerns of developing subarachnoid hemorrhage. Patients with recurrent ischemia, compromised cerebral blood flow or contraindications for antithrombotic agents are usually treated with open surgery or endovascular technique. Those with subarachnoid hemorrhage and intracranial artery dissection are often managed with surgical intervention due to high risk of re-hemorrhage.

How I do it: Sternocleidomastoid sparing approach for the right vertebral artery to common carotid artery transposition.

BACKGROUND: Direct surgery is an important option to treat vertebral artery (VA) stenosis. METHOD: A patient with symptomatic stenosis at the origin of the right VA underwent transposition of the right VA to the common carotid artery (CCA). Using the sternocleidomastoid sparing approach, the VA was anastomosed to the posterior wall of the CCA by twisting the CCA to expose its posterior wall to face the operative field. CONCLUSION: This approach, consisting of securing the proximal VA and then following it to its distal end, not only preserves the sternocleidomastoid muscle but also protects the sympathetic chains and thoracic duct.

Treatment of acute basilar artery occlusion by retrograde puncture via the vertebral artery approach: A care-compliant case report.

BACKGROUND: Vertebral artery stump syndrome (VASS) is a cause of acute stroke. Owing to the particularity of the pathogenesis of VASS, interventional treatment of VASS is difficult. Common mechanical thrombectomy approaches include femoral and radial artery approaches. However, conventional approaches may not be suitable for VASS. If effective measures are not taken to open offending vessels in time, this can lead to a high rate of disability. In recent years, no consensus has been reached regarding surgical methods for treating VASS. PATIENT CONCERNS: The patient presented to the emergency department with a 2-hour history of disturbance of consciousness. DIAGNOSIS: After neurological and magnetic resonance imaging examinations, the patient was diagnosed with acute large vessel occlusive posterior circulation cerebral infarction. METHODS: The patient's symptoms were not relieved after intravenous infusion of argatroban (10 mg) at a local hospital. We first attempted to open the occluded vertebral artery through normal approaches but failed. We then punctured the vertebral artery, successfully opened the occluded vertebral artery, and performed mechanical thrombectomy. RESULTS: The patient underwent successful vertebral artery puncture and mechanical thrombectomy, with no evidence of postoperative bleeding or vascular injury at the puncture site. The patient regained consciousness the day after surgery but remained impaired in physical activity. After 4 months of rehabilitation, the patient recovered completely. CONCLUSION: When the conventional approach cannot meet the requirements of mechanical thrombectomy, reverse puncture of the vertebral artery is a feasible surgical method for patients with VASS. However, due to the small number of cases, a series of safety problems such as potential puncture failure, hemorrhage after puncture, and vascular occlusion still need to be further explored.

A multidimensional pre-operative planning method of unruptured vertebral artery dissecting aneurysms using three-dimensional AWE mapping and hemodynamic simulation.

OBJECTIVE: High-resolution magnetic resonance imaging (HR-MRI) can provide valuable insights into the evaluation of vascular pathological conditions, and 3D digital subtraction angiography (3D-DSA) offers clear visualization of the vascular morphology and hemodynamics. This study aimed to investigate the potential of a multimodal method to treat unruptured vertebral artery dissection aneurysms (u-VADAs) by fusing image data from HR-MRI and 3D-DSA. METHODS: This observational study enrolled 5 patients diagnosed with u-VADAs, who were scheduled for interventional treatment. The image data of HR-MRI and 3D-DSA were merged by geometry software, resulting in a multimodal model. Quantified values of aneurysm wall enhancement (AWE), wall shear stress (WSS), neck velocity, inflow volume, intra-stent flow velocity (ISvelocity), and intra-aneurysmal velocity (IAvelocity) were calculated from the multimodal method. RESULTS: We found the actual lengths of u-VADAs in the multimodal model were longer than the 3D-DSA model. We formulated surgical plannings based on the WSS, IA velocity, and neck velocity. The post-operative value of IAvelocity, neck velocity, and follow-up quantified values of AWE were decreased compared with the pre-operative condition. After that, u-VADAs were complete occlusion in four patients and near-complete occlusion in one patient during the 6th-month follow-up after surgery. CONCLUSION: The multidimensional method combining HR-MRI with 3D-DSA may provide more valuable information for treating VADAs, with the potential to develop effective surgical planning.

Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options.

INTRODUCTION: Stump syndrome is defined as a clinical syndrome resulting from a distal intracranial vessel embolic stroke due to an extracranial vessel occlusion. Similar to the anterior circulation, the recurrence of ischemic strokes in territories supplied by the posterior circulation in the presence of vertebral artery occlusion is termed Vertebral Artery Stump Syndrome (VASS). MATERIAL AND METHODS: We conducted a literature review, identifying 72 patients with transient ischemic attacks (TIAs) or ischemic strokes attributed to VASS, according to Kawano criteria. We categorized all patients in two groups focusing on the therapeutic management those who underwent primary medical treatment and those who received endovascular or surgical treatment either in acute or chronic phase. RESULTS: In the anticoagulant therapy group, only 1 patient had a stroke recurrence. Among the 4 on antiplatelets, all had recurrences, but 3 benefited from switching to anticoagulants or endovascular therapy. In the endovascular therapy group, worse outcomes were linked to acute large vessel occlusion. Endovascular treatment of the vertebral artery, in a chronic phase, was explored in literature for recurrent TIAs or minor strokes suggesting that this could be a viable therapeutic alternative when medical treatment failed in preventing recurrence of ischemic stroke. CONCLUSIONS: Some studies suggest that anticoagulant medical therapy may be beneficial for VASS and endovascular therapy has also been reported for selected patients. However, data on treatment outcomes and prognosis are still underreported, making treatment decisions challenging. Randomized Controlled Trials are needed to establish the optimal treatment approach.

[Perfusion Methods and Reconstruction Techniques for Performing Aortic Arch Surgery with Isolated Left Vertebral Artery].

In our institution, when we perform aortic arch surgery with isolated left vertebral artery using an extracorporeal circulation, we select an interposed saphenous vein graft technique. This technique has a relatively short clamping time and allows for selective cerebral perfusion and flexible choice of reconstruction site. Although other techniques, such as an island reconstruction, have been reported, we do not perform it often due to its longer ischemic time of the left vertebral artery. On the other hand, we use a direct reconstruction technique in cases where an extracorporeal circulation is not used. This direct reconstruction technique in cases of isolated left vertebral artery could reduce the time and number of clamping it.

[Anatomical Variations to the Vertebral Artery and Posterior Inferior Cerebellar Artery are Associated with the Partial Persistence of Primitive Lateral Basirovertebral Anastomosis].

The angioarchitecture of the hindbrain is homologous to that of the spinal cord, and its vascular system can be analyzed at the longitudinal and axial structures. During embryonic development, there are two main longitudinal arteries: the longitudinal neural artery and the primitive lateral basilovertebral anastomosis. Commonly observed variations are formed by the fenestration and duplication of either the vertebrobasilar artery, or cerebellar artery, which can be observed when the primitive lateral basilovertebral anastomosis partially persists. Understanding the pattern and development of blood supply to the hindbrain provides useful information of various anomalies in the vertebrobasilar junction and cerebellar arteries.

Vertebral Artery Stenting for Acute Multiple Cerebral Infarctions Caused by Vertebral Artery Dissection After Massage: A Case Report.

Vertebral artery dissection is a rare pathology that can cause ischemic stroke in young people. Cervical massage, especially improper pulling manipulation, is a cause of vertebral artery dissection. We present a case of 32-year-old woman who developed acute multiple posterior circulation ischemic cerebral infarctions as a result of left vertebral artery V4 segment dissection after receiving neck massage. She underwent emergency vertebral artery stent implantation at the site of the dissection. Symptoms were relieved the day after treatment. The patient recovered without adverse complications or endovascular restenosis in the following year.