[Treatment of atherosclerotic lesion of the first segment of subclavian artery]. / Lechenie ateroskleroticheskogo porazheniya pervogo segmenta podklyuchichnoi arterii.

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Clinical response to surgical decompression in atypical pediatric Bow Hunter's syndrome suggesting alternative pathophysiology: Case report.

Bow Hunter's syndrome is a rare cause of posterior circulation ischemia, produced by the mechanical and reversible occlusion of the vertebral artery during cephalic rotation. Diagnosis requires clinical suspicion and careful inspection of images with three-dimensional reconstruction. The study of choice is dynamic digital subtraction angiography (DSA). Treatment alternatives are: medical, surgical or endovascular. We report the case of an 8-year-old boy with recurrent infarctions of the posterior circulation secondary to the dissection of the vertebral artery, in association with an occipital bone spur. Dynamic DSA was negative. Conservative initial management was elected with cervical immobilization and anticoagulation, but due to persistence of symptoms, surgical decompression was decided. The patient did not repeat symptoms postoperatively and returned to his usual life. This is the first case reported to our knowledge of a surgical pediatric patient with asymptomatic atypical compression of VA secondary to BHS, whose dynamic angiography was negative, suggesting an alternative mechanism of the syndrome.

Rare anatomic variation on a 10,000-year-old South American skeleton: the case of Iuzu, Toca dos Coqueiros, Piauí State, Brazil.

PURPOSE: A skeleton named Iuzu has been unearthed from an exceptional middle Holocene burial in Toca dos Coqueiros site, in Serra da Capivara National Park (UNESCO World Heritage Site, Piauí State, Brazil). During a bioarchaeological analysis of its remains, we discovered that Iuzu was suffering from rare vertebral malformations. A double foramen transversaria, the agenesis of a foramen on the atlas and the hypoplasia of the transverse process of the axis have been highlighted. We aimed to deduce the clinical consequences of the malformation on the patient's health. METHODS: We proceeded to macroscopic observation and radiography of the bones, then we search for other examples of such a pathology in archaeological litterature. RESULT: The malformation caused vascular insufficiency that may have led to neurological lesions leading to various pains and troubles. The very rare malformations Iuzu presented have not been found on a paleoindian skeleton from South America so far. CONCLUSION: This case allowed us to examine the conditions of selection of individuals buried in southern Piauí during the Middle Holocene, during which time this rite does not seem to predominate.

Relevance of the Pharmacokinetic and Pharmacodynamic Profiles of Puerariae lobatae Radix to Aggregation of Multi-Component Molecules in Aqueous Decoctions.

The complexity of traditional Chinese medicines (TCMs) is related to their multi-component system. TCM aqueous decoction is a common clinical oral formulation. Between molecules in solution, there exist intermolecular strong interactions to form chemical bonds or weak non-bonding interactions such as hydrogen bonds and Van der Waals forces, which hold molecules together to form "molecular aggregates". Taking the TCM Puerariae lobatae Radix (Gegen) as an example, we explored four Gegen decoctions of different concentration of 0.019, 0.038, 0.075, and 0.30 g/mL, named G-1, G-2, G-3, and G-4. In order of molecular aggregate size (diameter) the four kinds of solution were ranked G-1 < G-2 < G-3 < G-4 by Flow Cell 200S IPAC image analysis. A rabbit vertebrobasilar artery insufficiency (VBI) model was set up and they were given Gegen decoction (GGD) at a clinical dosage of 0.82 g/kg (achieved by adjusting the gastric perfusion volume depending on the concentration). The HPLC fingerprint of rabbit plasma showed that the chemical component absorption into blood in order of peak area values was G-1 < G-2 > G-3 > G-4. Puerarin and daidzin are the major constituents of Gegen, and the pharmacokinetics of G-1 and G-2 puerarin conformed with the two compartment open model, while for G-3 and G-4, they conformed to a one compartment open model. For all four GGDs the pharmacokinetics of daidzin complied with a one compartment open model. FQ-PCR assays of rabbits' vertebrobasilar arterial tissue were performed to determine the pharmacodynamic profiles of the four GGDs. GGD markedly lowered the level of AT1R mRNA, while the AT2R mRNA level was increased significantly vs. the VBI model, and G-2 was the most effective. In theory the dosage was equal to the blood drug concentration and should be consistent; however, the formation of molecular aggregates affects drug absorption and metabolism, and therefore influences drugs' effects. Our data provided references for the rational use of Chinese medicines in the clinic, such as the best oral preparation and decoction concentration.

Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management.

OBJECT: Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era. METHODS: A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up. RESULTS: Thirteen patients (8 women and 5 men, mean age 44 years, range 30-73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V(4) segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up. CONCLUSIONS: Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.

Experimental model of brainstem stroke in rabbits via endovascular occlusion of the basilar artery.

BACKGROUND: Basilar artery thrombosis remains a significant clinical problem, and no reproducible animal model has been established to study the stroke within the vertebrobasilar distribution. We report a study designed to pilot test a novel model of brainstem stroke in rabbits, created by selective endovascular occlusion of the basilar artery. METHODS: Basilar artery occlusion was induced in 8 New Zealand white rabbits by injection of the autologous clot through the microcatheter positioned within the distal vertebral artery. Animals were divided into subgroups (I and II) based on the length of produced ischemia (3 and 6 hours, respectively). Magnetic resonance (MR) imaging of the brain and MR angiography of the intracranial vessels were performed before the procedure, and at 3 hours after induced ischemia for groups I and II, with continued imaging up to 6 hours for group II, with diffusion-weighted images acquired approximately every 30 minutes. Animals were killed at the end of the 3-hour (group I) or 6-hour (group II) ischemia time. RESULTS: Brainstem stroke was successfully induced in all animals, with pathological changes documented in all cases. The earliest changes of ischemia on MR diffusion-weighted images were identified at only 4.5 hours of basilar artery occlusion. CONCLUSION: These results suggest that a reproducible model of brainstem stroke can be induced in rabbits using selective endovascular occlusion of the basilar artery. The availability of such a model, integrated with state-of-the-art imaging techniques, holds promise for preclinical investigations of emergent therapeutic approaches in stroke.

Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?

This synopsis provides an overview of the benign and serious risks associated with chiropractic care for subjects with neck or low-back pain. Most adverse events associated with spinal manipulation are benign and self-limiting. The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.

Vertebrobasilar ischemia after cervical spine manipulation: a case report.

INTRODUCTION: The most serious accidents after cervical spine manipulation are vertebrobasilar ischemia. Their incidence is underestimated. Their risk of apparition is lower if the contraindications are respected and if they are realised according to suitable practice. CASE REPORT: Mrs B, 39 years old, was an active smoker and had migraine for 10 years ago. One day, she presented an unusual headache associated with neck pain that was treated by a cervical spine manipulation. Seven hours after, she developed an alternate syndrome with a right sensory motor defect, a cerebellar syndrome, a pyramidal syndrome and a left defect of cranial nerves. The arteriography showed a thrombosis of the basilar trunk and a dissection of the left vertebral artery. A thrombolysis "in situ" was realized six hours and a half after the onset of the neurological defects. After eight months of rehabilitation, there were still a paralysis of the right upper limb, of the cranial nerves and a cerebellar syndrome but the patient was able to walk with two crutches and can eat by herself. DISCUSSION: Several risk factors were present in this case and there was also a major contraindication to manipulations: unusual acute occipital headache. Given the long period between the onset of neurological symptoms and the confirmation of the diagnosis, intravenous thrombolysis could not be done. Unfortunately, after eight months, important neurological sequels persisted. In order to avoid this type of accident after cervical manipulations, it is necessary to realize a strict medical examination and to implement the recommendations from the French society of manual and orthopaedic osteopathic medicine (Société française de médecine manuelle orthopédique et ostéopathique [SOFMMOO]).

Cervical arterial dysfunction and manual therapy: a critical literature review to inform professional practice.

An abundance of literature has attempted to provide insight into the association between cervical spine manual therapy and cervical artery dysfunction leading to cerebral ischaemic events. Additionally, specific guidelines have been developed to assist manual therapists in clinical decision-making. Despite this, there remains a lack of agreement within the profession on many issues. This paper presents a critical, re-examination of relevant literature with the aim of providing a contemporary, evidence-informed review of key areas regarding the neurovascular risks of cervical spine manual therapy. From a consideration of case reviews and surveys, haemodynamic principles, and blood flow studies, the authors suggest that: (1) it is currently impossible to meaningfully estimate the size of the risk of post-treatment complications; (2) existing testing procedures have limited clinical utility; and (3) a consideration of the association between pre-existing vascular risk factors, combined with a system based approach to cervical arterial haemodynamics (inclusive of the carotid system), may assist manual therapists in identifying at-risk patients.

Chiropractic manipulation: reasons for concern?

Chiropractic's popularity is rising among the general population. Moreover, few studies have been conducted to properly evaluate its safety. We report three cases of serious neurological adverse events in patients treated with chiropractic manipulation. The first case is a 41 years old woman who developed a vertebro-basilar stroke 48 h after cervical manipulation. The second case represents a 68 years old woman who presented a neuropraxic injury of both radial nerves after three sessions of spinal manipulation. The last case is a 34 years old man who developed a cervical epidural haematoma after a chiropractic treatment for neck pain. In all three cases there were criteria to consider a causality relation between the neurological adverse events and the chiropractic manipulation. The described serious adverse events promptly recommend the implementation of a risk alert system.

Cervical arterial dysfunction assessment and manual therapy.

In this paper, we present a clinical overview of cervical arterial dysfunction (CAD) for manual therapists who treat patients presenting with cervical pain and headache syndromes. An overview of vertebrobasilar arterial insufficiency (VBI) is given, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice is limited and present a more holistic, evidence-based approach to considering CAD. This approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors and pathomechanics of arterial dysfunction is also given. We suggest that consideration of the information provided in this Masterclass will enhance the manual therapist's clinical reasoning with regard to differential diagnosis of cervical pain syndromes, and prediction of serious adverse reactions to treatment.

Recovery in a patient with locked-in syndrome.

BACKGROUND AND PURPOSE: Sildenafil citrate has been shown to enhance neurogenesis, angiogenesis, synaptogenesis, and neurological outcome by augmentation of cyclic guanosine monophosphate (cGMP) levels in animal models of ischemic stroke. Whether sildenafil citrate may be helpful for recovery in human stroke is unknown at this time. METHODS: A 41-year-old woman with locked-in syndrome due to pontine infarction began receiving 150 mg of oral sildenafil citrate daily on a compassionate use basis in August 2003 and continues treatment at this time. Magneto-encephalography (MEG) was performed at 12 and 17 months after stroke. RESULTS: No serious adverse events have occurred. Significant milestone recoveries including standing, use of both arms, talking, and full return of swallowing have occurred, particularly after nine months of treatment. The MEG showed a significantly increased amplitude in the somatosensory cortex. CONCLUSION: Daily use of high dose sildenafil citrate appears to be safe in this patient with stroke resulting in locked-in syndrome. Further studies will be required to establish safety and efficacy.

Iatrogenic vertebral artery injury.

Iatrogenic vertebral artery injury (VAI) results from various diagnostic and therapeutic procedures. The objective of this article is to provide an update on the mechanism of injury and management of this potentially devastating complication. A literature search was conducted using PubMed. The iatrogenic VAIs were categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., central venous catheterization, cervical spine surgery, chiropractic manipulation, diagnostic cerebral angiography, percutaneous nerve block, and radiation therapy. The incidence, mechanisms of injury, and reparative procedures were discussed for each type of procedure. The type of VAI depends largely on the type of procedure. Laceration was the dominant type of acute injury in central venous catheterization and cervical spine surgery. Arteriovenous fistulae and pseudoaneurysms were the delayed complications. Arterial dissection was the dominant injury type in chiropractic manipulation and diagnostic cerebral angiography. Inadvertent arterial injection caused seizures or stroke in percutaneous nerve block. Radiation therapy was responsible for endothelial injury which in turn resulted in delayed stenosis and occlusion of the vertebral artery (VA). The proximal VA was the most vulnerable portion of the artery. Although iatrogenic VAIs are rare, they may actually be more prevalent than had previously been thought. Diagnosis of iatrogenic VAI may not always be easy because of its rarity and deep location, and a high level of suspicion is necessary for its early detection. A precise knowledge of the surgical anatomy of the VA is essential prior to each procedure to prevent its iatrogenic injury.

[Effect of vertebral manipulation therapy on vertebro-basilar artery blood flow in cervical spondylosis of vertebral artery type].

OBJECTIVE: To observe the effect of vertebral manipulation (VM) therapy on vertebro-basilar artery (VBA) blood flow in patients with cervical spondylosis of vertebral artery type (CS-VAT) by transcranial Doppler (TCD) ultrasonic examination. METHODS: One hundred and fifty patients with CS-VAT were randomized into the VM group (n = 100) and the acupuncture group (n = 50), and treated for ten times as one therapeutic course. Changes of the contraction peak, the end-diastolic and average blood flow velocity of VBA before and after treatment in the two groups were observed and compared by TCD. RESULTS: Vp, Vd, Vm of LVA, RVA and BA in the two groups after treatment were all lowered, showing significant difference, excepting Vp of VBA in the acupuncture group, when compared with before treatment (P< 0.05 or P <0.01). Comparison between the two groups after treatment showed significant difference in Vp and Vm of LVA, Vp, Vd and Vm of RVA, Vp and Vm of VBA respectively (P<0.05, P <0.01). CONCLUSION: VM therapy in treating patients with CS-VAT shows therapeutic effect superior to VA therapy, which could significantly improve VBA blood flow.