Extensive Lateral Cervical Desmoid Tumor Dependent on the Levator Scapulae Muscle Involving the Vertebral Artery Treated by Surgical Resection and Intraoperative Navigation: A Case Report and Review of the Literature.

Desmoid tumors are rare, benign, but locally aggressive fibromatoses that pose significant therapeutic challenges, particularly when located in the head and neck region. This report details the case of an extensive cervical desmoid tumor dependent on the levator scapulae muscle and involving the vertebral artery managed through surgical resection and intraoperative navigation. A 45-year-old male presented with a slowly growing cervical mass. Imaging revealed an 83x68x40 mm mass in the right lateral paravertebral space, dependent on the levator scapulae muscle and involving the vertebral artery. Biopsy confirmed a low-grade fusocellular myofibroblastic neoplasm consistent with a desmoid tumor. Given the poor prognosis associated with the symptomatic mass, surgical resection was performed using Brainlab intraoperative navigation (Brainlab, Munich, Germany). The procedure was successful, with preservation of vital structures and no evidence of recurrence postoperatively. Desmoid tumors in the head and neck region, though rare, require precise diagnostic and therapeutic approaches due to their aggressive nature and proximity to critical anatomical structures. The use of intraoperative navigation, in this case, facilitated accurate tumor resection, minimizing damage to surrounding tissues. Pathological analysis revealed a CTNNB1 gene mutation, specifically the S45P variant, which is associated with an increased risk of recurrence. This case highlights the importance of a multidisciplinary approach, incorporating advanced surgical techniques and genetic analysis, in the management of complex desmoid tumors. Intraoperative navigation proved invaluable in achieving successful surgical outcomes, underscoring its potential utility in similar cases. Continued follow-up is essential, given the potential for recurrence associated with desmoid tumors.

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.

A Case of Bony Stroke Involving a Vertebral Artery Detected by Dynamic Three-dimensional Computed Tomography Angiography.

When an ischemic stroke occurs due to bone or cartilage dynamically affecting vessels supplying the brain, it is called bony stroke. We herein report a patient with recurrent cryptogenic stroke that was thought to be a bony stroke. Dynamic three-dimensional computed tomography angiography revealed mechanical compression of the vertebral artery by the hyoid bone and thyroid cartilage. The patient had a recurrent stroke during antiplatelet therapy. Surgical removal of bone tissue prevents stroke recurrence.

Vertebral arteria lusoria-Hyrtl's original description (1859), case illustration, and literature analysis.

PURPOSE: A translation of the initial observation of vertebral arteria lusoria reported by Hyrtl in 1859 is followed by a review of all cases published until May 2023 to identify the anatomical and clinical features characterizing the typical form of this rare variant. METHODS: PubMed, Google Scholar, and Google queries were performed with "vertebral arteria lusoria", "retroesophageal vertebral artery", and "aberrant vertebral artery" as keywords (in English, German, and French). A feature was considered typical when present in at least 75% of analyzed cases. A case of incidentally discovered vertebral arteria lusoria illustrates the typical form of the variant. RESULTS: The analysis of 56 publications yielded 66 observations of right-sided vertebral arteria lusoria published between 1859 and May 2023. A small caliber, a retro-esophageal location, and passage through the foramen transversarium of C7 were typical. There was no evidence of association with clinical symptoms or other cardiovascular anomalies. CONCLUSION: A typical vertebral arteria lusoria is an incidentally discovered nondominant aberrant right VA originating from the proximal descending aorta and following a retro-esophageal course to enter the C7 foramen transversarium, without associated aortic arch branching anomalies or congenital cardiovascular pathologies.

[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.

C2 pedicle screw insertion assisted by mobilization of the vertebral artery in cases with high-riding vertebral artery.

Objective: To describe the feasibility, safety and efficacy of mobilization of the vertebral artery for C2 pedicle screws in cases with the high-riding vertebral artery (HRVA).. Methods: During the period January 2020 to September 2022, fifteen patients underwent posterior occipitocervical fixation in our department. All patients had unilateral HRVA on at least one side that prohibited the insertion of C2 pedicle screws. There were 2 males and 13 females aged 47 ± 11.9 years (range: 17-64 years). After the correction of the vertical dislocation during the operation, the C2 pedicle screw insertion and occipitocervical fixation and fusion were performed using the vertebral artery mobilization technique. A routine three-dimensional reconstructed CT examination was executed to confirm the trajectory of C2 pedicle screws post-operation, and a CT angiography examination was performed when necessary. Neurological function was assessed using the Japanese Orthopedic Association (JOA) scale. The preoperative and postoperative JOA score and the main radiological measurements, including anterior atlantodental interval (ADI), the distance of odontoid tip above Chamberlain line, and clivus-canal angle (CCA), were collected and compared by paired t-test. Results: All 15 patients had atlas assimilation, among which 12 patients had C2-C3 fusion (Klippel-Feil syndrome). Mobilization of the HRVA was successfully completed, and C2 pedicle screws were then fulfilled after the vertebral artery was protected. There was no injury to the vertebral artery during the operation. Meanwhile, no severe surgical complications such as cerebral infarction or aggravated neurological dysfunction occurred during the perioperative period. Satisfactory C2 pedicle screw placement and reduction were reached in all 15 patients. All the patients achieved bone fusion 6 months after surgery. No looseness and shift of internal fixation or reduction loss was observed during the follow-up period. Compared to the preoperative, the postoperative JOA score and the main radiological measurements were remarkably improved and statistically significant. Conclusions: C2 pedicle screw insertion assisted by mobilization of the vertebral artery is safe and considerably effective, providing a choice for internal fixation in cases with high-riding vertebral arteries.

[Repeated Bow hunter's stroke by artery-to-artery embolism from the vertebral artery dissecting aneurysm formed by head rotation: A case report].

A 55-year-old woman suffered from diplopia and occipital pain after shoveling snow. She was diagnosed with the right vertebral artery dissecting aneurysm at the level of the axial vertebra and repeatedly had cerebral infarctions in the posterior circulation. She had subluxation of the atlantoaxial vertebra as an underlying disease. Right vertebral angiogram with the head rotated to the left showed the right vertebral artery occlusion and left vertebral angiogram with the head rotated to the right showed stenosis at the C1-C2 level, leading to the diagnosis of Bow hunter's stroke. After wearing a cervical collar and taking 100 |mg of aspirin, she had no recurrence of cerebral infarction and later underwent C1-C2 posterior fusion to prevent the recurrence of cerebral infarction. She finished taking aspirin 6 months after the surgery, and there has been no recurrence of cerebral infarction. We report here a case of Bow hunter's stroke, a rare disease, with good clinical outcomes after C1-C2 posterior fusion.

Blunt Traumatic Vertebral Artery Injury After Cervical Fracture Dislocation: A Systematic Review of the Literature.

Certain high-energy blunt forces may produce unstable cervical fractures with or without dislocation. In rare cases where the superior facets are dislocated, however showing a significant increase within the last decade, these types of injuries may include vertebral artery entrapment at the involvement level leading to artery dissection or occlusion. This phenomenon is usually seen at the C4-C5 and C5-C6 levels of injury. A systematic review of the literature was performed by examining online databases such as PubMed - NCBI, Web of Science, Cochrane Library, Scopus, and Embase to identify relevant scientific articles. Keywords (MeSH terms) used in the search included cervical spine injuries, cervical spine dislocation, cerebrovascular injury, vertebral artery injury, vertebral artery injury management, and incidence of vertebral artery injury. Initially, 1516 studies were identified as a primary search for screening. After excluding papers that did not fulfill the inclusion criteria, 34 studies were included in this review. Vertebral artery injury consists of a severe complication that could compromise a surgical intervention since the patient's clinical image may be unrevealing at first. Early diagnosis and correct timing constitute the golden standard for adequate treatment. This systematic review aims to summarize the current evidence for the diagnosis, management, and treatment of blunt traumatic vertebral artery injuries.

Vertebral Artery Variation and Imposed Risks Associated with Anterior Cervical Discectomy and Fusion Procedures - A Case Study with Surgeons' Perspectives.

Introduction: Anterior cervical discectomy and fusion (ACDF) is a common cervical procedure with more than 137,000 cases in the United States (U.S.) each year. Historically, ACDF has been a relatively safe procedure despite encountering vital anatomical structures that can risk serious complications. One particularly dangerous sequela of ACDF is the risk of lacerating the vertebral artery (VA). While VA injuries are rare (0.5% of cases), it is crucial for surgeons to prevent this potentially deadly complication with thorough knowledge of VA anatomy. The VA is commonly protected within the transverse foreman; however, anomalies can exist with the artery potentially being found more medial or proximal within the surgical site than expected. The purpose of this article is to report an anomaly found in a cadaveric specimen, where the VA courses within 2 mm of an ACDF plate. Case Report: A 66-year-old male with a past medical history of coronary artery disease passed away due to complications of a myocardial infarction. During cadaveric dissection, it was discovered that the donor had undergone a previous 3-level (C4-C7) ACDF procedure for an unknown reason. Under further examination, the left VA was observed to take an anomalous medially tracking course before eventually entering the transverse foramina of C5. Left anterior tubercles were absent at the level of C5 and C6 with prominent osteophytes found on the anterior tubercles/transverse foramina of the contralateral side. Conclusion: There are no studies published on the anatomy of VA variants and their implications on ACDF procedures. ACDF was found to have complication rates in 13.2% of cases. VA variants are observed in up to 20% of the U.S. population and VA injury in ACDF procedures has a rate near 0.5%. With anatomic variations leading to a higher risk of injury, surgeons are required to take further precautionary steps before operating including ordering computed tomography angiography or magnetic resonance angiography films. Understanding the detailed anatomy of the VA and its variants is critical. Using the perspectives of orthopedic spine surgeons, this study supplements the literature on potential VA anomalies encountered in ACDF procedures.

Cervical Radiculopathy and Vertebrobasilar Insufficiency Secondary to Intraneural Foramen Vertebral Artery Loop: A Case Report.

This case report describes a 40-year-old male who presented with chronic neck pain radiating to the left upper limb, associated with weakness and numbness. He also had symptoms of vertebrobasilar insufficiency. Imaging revealed an intraneural foramen vertebral artery (VA) loop compressing the C3 nerve root. Conservative management was ineffective, prompting surgical decompression via a left C2-C3 facetectomy and foraminotomy. The patient experienced immediate pain relief and gradual improvement in weakness, with complete resolution of symptoms at the six-month follow-up. This case highlights the potential for VA loops to cause radiculopathy and the successful use of surgical decompression for treatment.

Gruppo Otologico's Experience in Managing the So-Called Inoperable Tympanojugular Paraganglioma.

Objective: to identify advanced or "so-called inoperable" cases of tympanojugular paragangliomas (PGLs) and analyze how each case is surgically managed and followed afterward. Study Design: a retrospective case series study. Methods: Out of 262 type C and D TJPs and more than 10 cases of advanced or so-called inoperable cases, files of 6 patients with a diagnosis of advanced tympanojugular PGLs who were referred to an otology and skull-base center between 1996 and 2021 were reviewed to analyze management and surgical outcomes. The criteria for choosing these cases involve having one or more of the following features: (1) a large-sized tumor; (2) a single ipsilateral internal carotid artery (ICA); (3) involvement of the vertebral artery; (4) a considerable involvement of the ICA; (5) an extension to the clivus, foramen magnum, and cavernous sinus; (6) large intradural involvement (IDE); and (7) bilateral or multiple PGLs. Results: The age range at presentation was 25-43 years old, with a mean of 40.5 years: two females and four males. The presenting symptoms were glossal atrophy, hearing loss, pulsatile tinnitus, dysphonia, shoulder weakness, and diplopia. The modified Infratemporal Fossa Approach (ITFA) with a transcondylar-transtubercular extension is the principal approach in most cases, with additional approaches being used accordingly. Conclusions: The contemporary introduction of carotid artery stenting with the direct and indirect embolization of PGLs has made it possible to operate on many cases, which was otherwise considered impossible to treat surgically. Generally, the key is to stage the removal of the tumor in multiple stages during the management of complex PGLs to decrease surgical morbidities. A crucial aspect is to centralize the treatment of PGLs in referral centers with experienced surgeons who are trained to plan the stages and manage possible surgical complications.

Mechanical Thrombectomy for Hyperacute Vertebrobasilar Ischemic Stroke via Nondominant Vertebral Artery : Clinical Experience and Considerations.

Objective: The dominant vertebral artery (VA) approach is primarily considered in mechanical thrombectomy (MT) for acute occlusion of the vertebrobasilar (VB) artery. As accessing the dominant artery is sometimes difficult, we present our experience treating acute VB stroke via a nondominant VA approach through a comparison with the dominant VA approach. Methods: Among 2,785 patients diagnosed with hyperacute ischemic stroke between January 2014 and December 2022, 50 patients with VB ischemic stroke underwent recanalization therapy through either dominant, nondominant, or bilateral VA approach. We evaluated patient characteristics and clinical course, highlighting the pros and cons of the access routes. Results: The patients with hyperacute VB ischemic stroke were predominantly male (72%), with a mean age of 68.12 years and an initial National Institutes of Health Stroke Scale (NIHSS) score mean of 17.1. Large-artery atherosclerosis (LAA, 48%) and cardio-embolism (CE, 36%) were the main etiologic factors in the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. After thrombectomy, 45 (90%) cases had final modified thrombolysis in cerebral infarction (mTICI) score of 2b or higher. In summary, 41 patients were treated through the dominant VA, and 8 patients underwent the nondominant VA approach. However, there was no statistically significant difference in functional outcome or mortality between the two approaches. Conclusion: In MT for VB occlusions, nondominant VA approach may be an option in situations when the vessel is accessible, stable, or less risky, as recanalization can be achieved without rescue balloon angioplasty and/or stenting.

Exploring the atlantic part of the vertebral artery in the South Indian Population and its implications in spine surgery.

Study Design: A descriptive, quantitative cross-sectional study of the atlantic part (V3) of the vertebral artery (VA). Purpose: This study aimed to bridge the research gap in the morphometry of the V3 segment of the VA in the South Indian population. Overview of Literature: The microsurgical anatomy of this segment of the VA has been explored in various populations, and a thorough understanding of the anatomy and course of the VA, particularly the V3 segment, is essential to prevent iatrogenic complications. Several computed tomography studies but a few cadaveric studies have explored the V3 segment of the VA in the South Indian population. Methods: This study examined 40 VAs from 20 embalmed cadavers that were obtained from the voluntary donation program, and Institutional Ethical Clearance was obtained before the study. The length, diameter, and angle of the vertical, horizontal, and exit parts of the V3 segment of the VA were documented after its exposure. Results: The mean lengths of the right and left VAs on each part were nearly similar, except for the mean length of the horizontal part (right: 38.937 mm, left: 40.237 mm) and total length of the V3 segment (right: 66.870 mm, left: 70.350 mm). Conclusions: These morphometric parameters are essential to spine surgeons who intend to operate on a small part (vertical, horizontal, or exit part) of the V3 segment of the VA. The mean values of the parameters obtained in this study give average measurements or safe limits to surgeons for safe surgical procedures such as the occipital condyle screw technique and C1 laminectomy.

Retrospective case series of vertebral artery injuries associated with cervical spine trauma.

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

Vertebral artery injury following combination Jefferson fracture of C1 and Type II odontoid fracture: A case report.

Traumatic posterior atlantoaxial dislocation combined with Jefferson fracture and odontoid process fracture with vertebral artery injury is rare. The management of such injury raises controversial issues and is still open to debate. A 74-year-old Chinese male presented with sustained neck pain and stiffness after falling from height. The patient was neurologically intact. Preoperative radiographs demonstrated a Jefferson burst fracture with a posterior dislocation of the atlantoaxial joints and odontoid process Anderson and D'alonzo type II fracture. A computed tomography angiography (CTA) showed an occluded left vertebral artery. Coil embolization in the proximal portion of the occluded vertebral artery was performed to prevent further cerebral infarction due to distal embolization of the thrombus. Then a second stage occipito-cervical fusion was performed to reconstruct cervical spine stability. A systematic screening of blunt trauma vertebral artery injuries through CTA is required when dealing with upper cervical fracture. For cases with vertebral artery occlusion secondary to cervical spine injury, endovascular treatment preceding cervical spine surgery is a feasible and a safe treatment.

Strategies and outcomes of endovascular treatment of posterior inferior cerebellar artery aneurysms: a single center experience.

To explore safe and reliable strategies and outcomes of endovascular procedures in the treatment of posterior inferior cerebellar artery (PICA) aneurysms. Retrospectively reviewed and analyzed the cases of PICA aneurysms that undergone endovascular therapy from July 2017 through January 2022 in our neurosurgical center, as well as outcomes of long-term follow-up. Total 24 cases were enrolled. Majority of the PICA aneurysms (87.5%, 21/24) presented initially with subarachnoid hemorrhage (SAH) and only 3 cases were not ruptured when they were clinically diagnosed as PICA aneurysms. The patients were endovascularly given either aneurysm occlusion with selective coils (12 cases), embolization of aneurysms and parent arteries (7 cases: 3 cases with coils and 4 cases with Onyx liquid embolic agent), or stent-assisted coiling of the aneurysms (5 cases). One patient, who had comorbidity of intracranial hemorrhage and severe cerebral vasospasm, declined further post-surgery therapy, and discharged from the hospital with anticipation of poor outcome. The rest 23 patients were followed up for 3-24 months with a recurrence rate of 17.4% (4/23). Endovascular procedure of embolizing PICA aneurysms with selective coils or stent-assisted coils is feasible, safe, and reliable. Simplified embolization of the aneurysms or occlusion of the parent artery is recommended as the first choice for the ruptured and bleeding PICA aneurysms.

Treatment of medullary aneurysm in the collateral circulation with a flow diverter: A case report.

INTRODUCTION AND IMPORTANCE: Spinal aneurysms rarely occur in the collateral circulation of the vertebral artery (VA). These aneurysms are difficult to treat. A flow diverter (FD) can be a therapeutic option. CASE PRESENTATION: A 62-year-old man suffered subarachnoid hemorrhage. His Hunt-Hess scale classification was grade II. Digital subtraction angiography (DSA) revealed that the bilateral distal VAs were occluded, there were two flow-related aneurysms in the collateral circulation of the first radicular artery of the VA, and there was a dissecting aneurysm at the origin of the posterior inferior cerebellar artery (PICA). The FD covered the PICA dissecting aneurysm, and the first radicular artery originated in the VA. Postoperatively, computed tomography angiography revealed a patent PICA and regression of the aneurysm in the collateral circulation. At the one-month follow-up, he showed good recovery and was therefore allowed to return to work. Follow-up DSA confirmed the regression of the aneurysms. However, the intracranial VA and PICA were unexpectedly occluded. CLINICAL DISCUSSION: It is difficult to catheterize aneurysms in the collateral circulation to perform coiling. It is also dangerous to embolize such aneurysms with a liquid embolic agent. After FD deployment to cover the origin of the parent artery, the hemodynamic stress of the aneurysm decreases, and the aneurysm can regress. CONCLUSION: Aneurysms in the collateral circulation were not accessible. FD deployment in the parent artery to cover the origin of the feeding artery of the collateral circulation is feasible for treating such aneurysms.

Anatomical and surgical considerations for Bow Hunter's syndrome in an elderly patient.

Bow Hunter's syndrome (BHS) is an uncommon condition characterized by impingement of one of the two vertebral arteries induced by cervical rotation, causing symptomatic vertebrobasilar insufficiency of the posterior cerebral circulation. We report a case of BHS in an 84-year-old male. Two months following a motor vehicle accident, the patient presented to an urgent care facility with subsequent transfer to the emergency department with complaints of lightheadedness upon right-lateral head movement. A cerebral angiogram demonstrated mild focal stenosis in the dominant left vertebral artery at the C2 level when in neutral position with significant worsening of the stenosis in the right-lateral head position with absent anterograde flow, consistent with BHS. Resultantly, the patient was referred for neurosurgery and successfully underwent placement of right-sided C2-C4 postero-lateral instrumentation and left-sided C2-C3 laminar screws projected towards the right side. This case highlights the importance of imaging in BHS diagnosis and guidance for treatment, as well as the need for a surgical standard of care for BHS patients.

A combined endovascular and open repair of innominate artery bifurcation pseudoaneurysm: a case report.

BACKGROUND: Innominate artery aneurysms (IAAs) are rare and may result in rupture, distal arterial embolization, or local compression without timely treatment. Rupture is the most dangerous of these complications. This article reports a case of innominate artery bifurcation pseudoaneurysm. CASE PRESENTATION: The patient was a 45-year-old man who was admitted to the emergency department due to chest discomfort. The computed tomographic angiography (CTA) imaging indicated the presence of a 3.6*2.4 cm saccular aneurysm in the bifurcation of the innominate artery, involving both the right proximal subclavian and common carotid arteries. The patient's vital signs were normal, there was equal blood pressure in the upper arms and no neurological dysfunction was observed. Gadolinium-enhanced magnetic resonance angiography indicated that the circle of Willis was intact. The treatment involved open surgery combined with endovascular therapy. The external carotid artery was first transposed to the right subclavian artery (RSA) and an 8-mm woven Dacron graft was inserted in the middle. The covered stent graft was then placed in the proximal part of the innominate artery to close the entrance of the aneurysm. Lastly, an occluder was implanted at the origin of the RSA. There were no perioperative or postoperative complications. At 1-year follow-up, no aneurysm was observed on CTA and the right vertebral artery was patent. CONCLUSIONS: This study indicated that the combined use of endovascular therapy and open repair surgery is an effective strategy to treat innominate artery bifurcation pseudoaneurysm.