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.

An infection-oriented approach for thoracic endovascular aortic repair in a SARS-CoV-2 positive patient. A case report.

CASE REPORT: A 64-year-old woman presented to our emergency department during the outbreak of the covid-19 emergency in Italy with syncope, anosmia, mild dyspnoea and atypical chest and dorsal pain. A chest CT scan showed an acute type B aortic dissection (ATBAD) and bilateral lung involvement with ground-glass opacity, compatible with interstitial pneumonia. Nasopharyngeal swabs resulted positive for SARS-CoV-2. For the persistence of chest pain, despite the analgesic therapy, we decided to treat her with a TEVAR. Patient's chest and back pain resolved during the first few days after the procedure. No surgical or respiratory complications occurred and the patient was discharged 14 days after surgery. DISCUSSION: By performing the operation under local anesthesia, it was possible to limit both the staff inside the operatory room and droplet/aerosol release. Since we had to perform the operation in a hemodynamics room, thanks to the limited extension of the endoprosthesis and the good caliber of the right vertebral artery we were able to reduce the risk of spinal cord ischemia despite the lack of a revascularization of the left subclavian artery. CONCLUSIONS: A minimally invasive total endovascular approach allows, through local anesthesia and percutaneous access, to avoid surgical cut down and orotracheal intubation. This, combined with a defined management protocol for infected patients, seems to be a reasonable way to perform endovascular aortic procedures in urgent setting, even in a SARSCoV- 2 positive patient. KEY WORDS: COVID-19, Dissection, TEVAR.

Cervical artery dissection related to chiropractic manipulation: One institution's experience.

PURPOSE: The purpose of this study was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation. METHODS: We identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuroradiologist to confirm the findings of a cervical artery dissection and stroke. We conducted telephone interviews to ascertain the presence of residual symptoms in the affected patients. RESULTS: Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. We obtained follow-up information on 9 patients, 8 of whom had residual symptoms and one of whom died as a result of his injury. CONCLUSION: In this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.

Advances and innovations in revascularization of extracranial vertebral artery.

Revascularization of the extracranial vertebral artery has evolved significantly since the adoption of endovascular techniques. The current neurosurgical armamentarium includes microsurgical and endovascular approaches. The indications for each treatment modality, however, still need to be further delineated. In contrast to carotid artery endarterectomy and carotid artery angioplasty/stenting, there is limited comparative evidence on the efficacy of medical, open, and endovascular treatment of atherosclerotic disease of the extracranial vertebral artery. More recently, drug-eluting stents have gained momentum after high rates of in-stent restenosis have been reported with bare metal stents placed in the vertebral artery. In this article, we discuss the indications, clinical assessment, and surgical nuances of microsurgical and endovascular revascularization for atherosclerotic disease of the extracranial vertebral artery. Despite a general tendency to consider endovascular treatment in the majority of patients, ultimately, open and endovascular revascularization of extracranial vertebral artery should be regarded as complementary therapies and both treatment options need to be discussed in selected patients.

Dissection of the posterior inferior cerebellar artery in a young adult with cerebellar infarct.

The posterior inferior cerebellar artery (PICA) is frequently involved in dissection of the vertebral artery (VA); however, isolated PICA dissection has rarely been reported. A 37-year-old man experienced acute and progressive drowsiness, vertigo, occipital headache, vomiting, and ataxia. There was no precedent trauma or chiropractic manipulation. Neurologically, he had dysmetria of the left extremities. His NIHSS score was 3. Brain magnetic resonance imaging showed an acute cerebellar infarct in the left PICA territory. Magnetic resonance angiography showed a faint signal adjacent to the junction of the left VA and PICA, suggesting a vascular shadow. Catheter angiography showed focal stenosis with a post-stenotic fusiform aneurysmal dilatation of the left proximal PICA that was highly suggestive of dissection with pseudoaneurysm formation. He was treated with clopidogrel and was free of neurological symptoms 3 months after the stroke event. Isolated PICA dissection may be considered in patients with PICA territory infarct or subarachnoid hemorrhage. Treatment depends on the manifestations; ruptured dissecting aneurysms are often treated with surgery or embolization, and infarcts are usually treated with antithrombotic agents.

Spontaneous vertebral arteriovenous fistula--case report.

A 57-year-old male presented with a rare case of spontaneous vertebral arteriovenous fistula manifesting as radiculopathy of the right arm, subsequently associated with pulsating tinnitus and vascular bruit in the nape. He had a past history of chiropractic-induced vertebrobasilar infarction. Angiography showed a simple and direct fistula between the third segment of the right vertebral artery and the epidural veins at the C-1 level, where the artery runs backward above the arch of the C-1 just proximal to the penetration of the dura. The fistula was successfully obliterated by coil embolization, resulting in rapid improvement of the signs and symptoms. Mechanical compression to the nerve roots by the engorged epidural veins with arterial pressure was considered to be the major cause of radiculopathy. Vertebral artery dissection induced by chiropractic manipulation is most likely responsible for the development of the fistula.

Vertigo as manifestation of vertebral artery dissection after chiropractic neck manipulations.

We recently observed a case of vertebral artery (VA) dissection following chiropractic neck manipulations. The first manifestation was unusual; in the form of vertigo. Therefore, the patient was referred to the otoneurologist. A VA dissection should be suspected in a case of vertigo following chiropractic neck manipulations, and vestibular tests should be done carefully, avoiding Rose's positions. In our case, the diagnosis was based on Doppler sonography and angiography. Chiropractic neck manipulations are the most frequent cause of traumatic VA dissection. Practitioners should be aware that, in some cases, these manoeuvres are life threatening.

Surgery of vertebrobasilar aneurysms and nimodipine.

Five patients among 60 consecutive patients suffering from recent subarachnoid hemorrhage were operated for ruptured vertebrobasilar aneurysm. Topical nimodipine treatment was given during the operation after clipping and continued systemically for three weeks. One out of the five patients developed symptoms which could be ascribed to delayed arterial vasospasm. Nimodipine may be advantageous in preventing ischemic complications when used prophylactically. Further investigation is needed to elucidate its efficacy in cases of vertebrobasilar aneurysms and conventional timing of surgery.