Effects of Head and Neck Positions on Blood Flow in the Vertebral, Internal Carotid, and Intracranial Arteries: A Systematic Review.

BACKGROUND: Manual therapy interventions targeting the neck include various positions and movements of the craniocervical region. The hemodynamic changes in various spinal positions potentially have clinical relevance. OBJECTIVES: To investigate the effects of craniocervical positions and movements on hemodynamic parameters (blood flow velocity and/or volume) of cervical and craniocervical arteries. METHODS: A search of 4 databases (PubMed, Embase, CINAHL, and Index to Chiropractic Literature) and, subsequently, a hand search of reference lists were conducted. Full-text experimental and quasi-experimental studies on the influence of cervical positions on blood flow of the vertebral, internal carotid, and basilar arteries were eligible for this review. Two independent reviewers selected and extracted the data using the double-screening method. RESULTS: Of the 1453 identified studies, 31 were included and comprised 2254 participants. Most studies mentioned no significant hemodynamic changes during maximal rotation (n = 16). A significant decrease in hemodynamics was identified for the vertebral artery, with a hemodynamic decrease in the position of maximum rotation (n = 8) and combined movement of maximum extension and maximum rotation (n = 4). A similar pattern of decreased hemodynamics was also identified for the internal carotid and intracranial arteries. Three studies focused on high-velocity thrust positioning and movement. None of the studies reported hemodynamic changes. The synthesized data suggest that in the majority of people, most positions and movements of the craniocervical region do not affect blood flow. CONCLUSION: The findings of this systematic review suggest that craniocervical positioning may not alter blood flow as much as previously expected. LEVEL OF EVIDENCE: Therapy, level 2a. J Orthop Sports Phys Ther 2019;49(10):688-697. Epub 5 Jul 2019. doi:10.2519/jospt.2019.8578.

Predictive value of SAR based quality indicators for head and neck hyperthermia treatment quality.

PURPOSE: Hyperthermia treatment quality determines treatment effectiveness as shown by the clinically derived thermal-dose effect relations. SAR based optimization factors are used as possible surrogate for temperature, since they are not affected by thermal tissue properties uncertainty and variations. Previously, target coverage (TC) at the 25% and 50% iso-SAR level was shown predictive for treatment outcome in superficial hyperthermia and the target-to-hot-spot-quotient (THQ) was shown to highly correlate with predictive temperature in deep pelvic hyperthermia. Here, we investigate the correlation with temperature for THQ and TC using an 'intermediate' scenario: semi-deep hyperthermia in the head & neck region using the HYPERcollar3D. METHODS: Fifteen patient-specific models and two different planning approaches were used, including random perturbations to circumvent optimization bias. The predicted SAR indicators were compared to predicted target temperature distribution indicators T50 and T90, i.e., the median and 90th percentile temperature respectively. RESULTS: The intra-patient analysis identified THQ, TC25 and TC50 as good temperature surrogates: with a mean correlation coefficient R2T50 = 0.72 and R2T90=0.66. The inter-patient analysis identified the highest correlation with TC25 (R2T50 = 0.76, R2T90=0.54) and TC50 (R2T50 = 0.74, R2T90 = 0.56). CONCLUSION: Our investigation confirmed the validity of our current strategy for deep hyperthermia in the head & neck based on a combination of THQ and TC25. TC50 was identified as the best surrogate since it enables optimization and patient inclusion decision making using one single parameter.

Venous Malformations of the Head and Neck.

Venous malformations (VMs) of the head and neck arise from deficits in the development of venous network. Clinically, VMs are highly variable, from small and asymptomatic varicosities to massive cervicofacial lesions. Therapeutic approaches include surgery; laser photocoagulation; sclerotherapy; and, more recently, systemic targeted drugs. This article discusses the natural history, diagnosis, and management of VMs.

Ethanol sclerotherapy of head and neck venous malformations.

OBJECTIVE: This retrospective study evaluated the results of sclerotherapy with low doses of ethanol for treatment of head and neck venous malformations. METHODS: We treated 51 patients, 37 females. Median age was 23 years. Patients were treated with percutaneous intralesional injection of alcohol every two weeks and followed up prospectively for a median period of 18 months. Most lesions affected the face and cosmetic disfigurement was the most frequent complaint. RESULTS: We performed a median of 7 sessions of sclerotherapy. Complete resolution or improvement was observed in 48 patients presented. Five cases of small skin ulceration, two cases of hyperpigmentation and two of paresthesia were documented; all of them were treated conservatively. CONCLUSION: Percutaneous sclerotherapy with low doses of ethanol is a safe and effective treatment modality for venous malformations affecting the head and neck.

Ethanol sclerotherapy of head and neck venous malformations / Escleroterapia com etanol em malformações venosas da cabeça e pescoço

Objective This retrospective study evaluated the results of sclerotherapy with low doses of ethanol for treatment of head and neck venous malformations. Methods We treated 51 patients, 37 females. Median age was 23 years. Patients were treated with percutaneous intralesional injection of alcohol every two weeks and followed up prospectively for a median period of 18 months. Most lesions affected the face and cosmetic disfigurement was the most frequent complaint. Results We performed a median of 7 sessions of sclerotherapy. Complete resolution or improvement was observed in 48 patients presented. Five cases of small skin ulceration, two cases of hyperpigmentation and two of paresthesia were documented; all of them were treated conservatively. Conclusion Percutaneous sclerotherapy with low doses of ethanol is a safe and effective treatment modality for venous malformations affecting the head and neck. .

Objetivo Estudo retrospectivo que analisou os resultados da escleroterapia, com doses baixas de etanol, realizada sob anestesia local para tratamento de malformações venosas na cabeça e pescoço. Métodos Foram tratados 51 pacientes, sendo 37 do gênero feminino. A mediana de idade foi de 23 anos. Os pacientes foram tratados com injeções alcoólicas nas lesões, por via percutânea, em sessões quinzenais, e acompanhados prospectivamente por um período mediano de 18 meses. A maioria das lesões acometia a face e a queixa principal mais frequente foi deformidade estética. Resultados Foram realizadas, em média, sete sessões de escleroterapia. Resolução completa ou melhora foi observada em 48 pacientes. Cinco pacientes apresentaram pequena úlcera cutânea, dois hiperpigmentação e dois parestesia, sendo todos tratados conservadoramente. Conclusão A escleroterapia percutânea com doses baixas de etanol é um método seguro e eficaz para tratar malformações venosas na cabeça e pescoço. .

Embolization of the neck lymphatic varix, causing periodic neck swelling.

We report a case of a 44-year-old female patient, presented to us after years of recurrent intermittent episodes of unilateral left neck swelling. An MR lymphangiogram demonstrated a lymphatic varix at the confluence of the left upper extremity lymphatic ducts, confirmed by intranodal axillary lymphangiography. After successful catheterization of the feeding lymphatic vessels, the varix was successfully embolized with detachable microcoils and an autologous blood patch. The patient has been free from symptoms on subsequent outpatient follow-up.

A case of central retinal artery occlusion after chiropractic manipulation of the neck.

Here we report a case of central retinal artery occlusion after chiropractic manipulation on the neck. A 49-year old man presented at the hospital because of sudden visual loss in his right eye after chiropractic neck manipulation. He had received chiropractic manipulation of the neck by a chiropractor eight days prior. When he first visited us, his best corrected visual acuity in his right eye was hand motion. A full ophthalmic examination was performed. There was cherry-red spot in the macula in his right eye. We performed a fluorescein angiogram and cervical color Doppler. The arterio-venous transit time in the fluorescein angiogram was delayed, and we detected stenosis of the right internal carotid artery with diffuse atherosclerotic plaques in the right common carotid artery. We prescribed ginko biloba extract (Tanamin). Three years after his first visit, the best corrected visual acuity of his right eye was 20 / 200.

A Case of Central Retinal Artery Occlusion after Chiropractic Manipulation of the Neck

Here we report a case of central retinal artery occlusion after chiropractic manipulation on the neck. A 49-year old man presented at the hospital because of sudden visual loss in his right eye after chiropractic neck manipulation. He had received chiropractic manipulation of the neck by a chiropractor eight days prior. When he first visited us, his best corrected visual acuity in his right eye was hand motion. A full ophthalmic examination was performed. There was cherry-red spot in the macula in his right eye. We performed a fluorescein angiogram and cervical color Doppler. The arterio-venous transit time in the fluorescein angiogram was delayed, and we detected stenosis of the right internal carotid artery with diffuse atherosclerotic plaques in the right common carotid artery. We prescribed ginko biloba extract (Tanamin). Three years after his first visit, the best corrected visual acuity of his right eye was 20 / 200.

Subcutaneous hematoma associated with manual cervical massage during carotid artery stenting. A case report.

We describe a patient with subcutaneous hematoma associated with manual cervical massage during carotid artery stenting.A 73-year-old man with left cervical carotid artery stenosis presented with left amaurosis fugax. We performed carotid artery stenting using distal embolic protection with balloon occlusion. Dual antiplatelet therapy was maintained in the periprocedural period and an anticoagulant agent was administered during the procedure. Because the aspiration catheter became entrapped by the stent, it did not reach the distal side of the stenotic lesion, and manual compression of the cervical region was therefore performed. Immediately afterwards, a subcutaneous hemorrhage occurred in the cervical region. There was no postoperative dyspnea due to enlargement of the hematoma, which was absorbed spontaneously.Cervical subcutaneous hematoma can occur in the cervical region due to cervical massage in patients who are receiving adjuvant antiplatelet therapy and anticoagulation therapy.

When to manage level V in head and neck carcinoma?

OBJECTIVES/HYPOTHESIS: As superselective neck dissection strategy is gaining popularity to minimize postoperative morbidity and better life quality, we investigated the metastatic nodal status of level V neck lymph node group for head and neck squamous cell carcinoma in various primary sites. We have also aimed to display the impact of involvement of other nodal groups on level V. STUDY DESIGN: Retrospective review of histopathologic examination of case series at a comprehensive cancer center. METHODS: The study group was composed of 107 patients who underwent a type of neck dissection including level V among 243 patients. The impact of primary site and metastatic nodal status of other levels on metastasis to level V involvement were evaluated. RESULTS: The most common primary tumor site was oropharynx (n = 43), followed by oral cavity (n = 32), larynx (n = 16), carcinoma of unknown primary (n = 10), and hypopharynx (n = 6). General pathologic N positivity for all levels was 78.3% (76 of 97) when 10 carcinoma of unknown primary patients were excluded. Level V was involved in 13 of 107 (12.1%) patients. Level V was not involved in any patient when the other levels were not involved (0 of 21). Even when considering only N+ patients, the ratio of N positivity for level V is still <20% (13 of 86, 15.1%). CONCLUSIONS: Because level V was not involved in any patient when the other levels were not involved, it might be reasonable to preserve level V especially in clinically and intraoperatively N0 patients.

Potential neuroprotective effects of acupuncture stimulation on diabetes mellitus in a global ischemic rat model.

Acupuncture (ACU) is known to be effective in ischemia treatment, and glutamate (GLU) excitotoxicity is an important factor in neuronal cell death. We observed the effect of ACU on cerebral blood flow (%CBF) and DeltaGLU (the changes in GLU release) in the ischemic stroke rat model of diabetic mellitus (DM). A global ischemia was induced using the eleven-vessel occlusion (11-VO) method in 14 Sprague-Dawley rats (DM), which were randomly divided into two groups: the control group and the ACU-treatment group. Extracellular DeltaGLU was assessed using an intra-cerebral biosensor system measuring 256 samples per second, simultaneously with %CBF and electroencephalogram. ACU stimulation was applied to ACU points GB34 and GB39 during the ischemic period. Twenty-three diagnostic parameters were proposed first for a detailed analysis of changes in %CBF and GLU release during ischemia/reperfusion. ACU rats showed a significant decrease in ischemic (p < 0.05) and reperfusion %CBF (p < 0.0001) than control rats, and a significantly larger decrease in ischemic DeltaGLU (p < 0.05) and peak level of reperfusion DeltaGLU (p < 0.005) than control rats. From these results, we suggest that ACU stimulation is responsible for the potential protection of neurons through suppression of %CBF response in the increased plasma osmolality and extracellular DeltaGLU in diabetic rats under ischemic conditions.

Athletics, minor trauma, and pediatric arterial ischemic stroke.

Pediatric arterial ischemic stroke may occur as the result of trivial head or neck trauma sustained during a sports activity. We describe three cases of sports-related stroke in previously healthy school-age children and discuss acute and long-term stroke care. Possible mechanisms of sports-related stroke are addressed, as is evaluation for cause of stroke in children. In one of the reported cases, the child was found to have a vertebral artery dissection as the cause of his stroke, but no definitive cause of stroke was identified in the other two cases despite extensive evaluation. The advisability and timing of returning to athletic activities after stroke is also discussed. Many children with sports-related stroke are initially seen by a sports trainer, a pediatrician, or an ER physician. Thus, it is particularly important that these professionals are aware of the possibility of ischemic stroke occurring after even mild athletic injury. Childhood stroke may result from injuries sustained during athletic activities and should be considered when a child has acute focal neurologic signs.

Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists.

SYNOPSIS: This clinical commentary provides evidence-based information regarding adverse cerebrovascular events in the context of manual therapy assessment and management of the cervical spine. Its aim is to facilitate clinical decision making during diagnosis and treatment of patients presenting to the therapist with cervicocranial pain. Rather than focusing on a traditional view of premanipulative testing as the cornerstone for decision making, we present information concerning the clinical presentation of specific vascular conditions. Additionally, we discuss the assessment and management of musculoskeletal pain in the presence of risk factors for cerebrovascular accident. It is proposed that vascular "red flag" presentations mimic neuromusculoskeletal cervicocranial syndromes. Invariably, the 2 conditions coexist. This reasoning presupposes that some patients who have poor clinical outcomes, or a serious adverse response to treatment, may be those who actually present with undiagnosed vascular pathology. We use 2 case reports to demonstrate how incorporating vascular knowledge into clinical reasoning processes may influence clinical decision making. LEVEL OF EVIDENCE: Level 5.

Test characteristics of neck fullness and witnessed neck pulsations in the diagnosis of typical AV nodal reentrant tachycardia.

BACKGROUND: Claims in the medical literature suggest that neck fullness and witnessed neck pulsations are useful in the diagnosis of typical AV nodal reentrant tachycardia (AVNRT). HYPOTHESIS: Neck fullness and witnessed neck pulsations have a high positive predictive value in the diagnosis of typical AVNRT. METHODS: We performed a cross-sectional study of consecutive patients with palpitations presenting to a single electrophysiology (EP) laboratory over a 1 year period. Each patient underwent a standard questionnaire regarding neck fullness and/or witnessed neck pulsations during their palpitations. The reference standard for diagnosis was determined by electrocardiogram and invasive EP studies. RESULTS: Comparing typical AVNRT to atrial fibrillation (AF) or atrial flutter (AFL) patients, the proportions with neck fullness and witnessed neck pulsations did not significantly differ: in the best case scenario (using the upper end of the 95% confidence interval (CI), none of the positive or negative predictive values exceeded 79%. After restricting the population to those with supraventricular tachycardia (SVT) other than AF or AFL, neck fullness again exhibited poor test characteristics; however, witnessed neck pulsations exhibited a specificity of 97% (95% CI: 90%-100%) and a positive predictive value of 83% (95% CI: 52%-98%). After adjustment for potential confounders, SVT patients with witnessed neck pulsations had a seven-fold greater odds of having typical AVNRT, p = 0.029. CONCLUSIONS: Although neither neck fullness nor witnessed neck pulsations are useful in distinguishing typical AVNRT from AF or AFL, witnessed neck pulsations are specific for the presence of typical AVNRT among those with SVT.

Cervical artery dissection. A comparison of highly dynamic mechanisms: manipulation versus motor vehicle collision.

OBJECTIVE: To examine the similarities and dissimilarities between cervical chiropractic manipulative therapy and whiplash, and their respective relation to cervical artery dissection. DATA SOURCES: A literature synthesis used MEDLINE-PubMed and MANTIS literature searches. A total list of 99 relevant articles was generated. Additional references were collected from citations incorporated within the included articles. RESULTS: Both neck manipulation and motor vehicle collision events apply loads to the spinal column rapidly. While neck manipulation loads are slower to develop and displacements smaller, they may reach peak amplitudes on maximum effort comparable to those seen in low-velocity collision experiments. In contrast to reports that the vertebral artery experiences elongations exceeding its physiological range by up to 9.0 mm during simulated whiplash, strains incurred during cervical manipulative therapy have been reported to be approximately one ninth of those required for mechanical failure, comparable to forces encountered in the course of diagnostic range of motion examination. Additionally, long-lasting abnormalities of blood flow velocity within the vertebral artery have been reported in patients following common whiplash injuries, whereas no significant changes in vertebral artery peak flow velocity were observed following cervical chiropractic manipulative therapy. CONCLUSIONS: Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely. The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures.

Comparing microvascular outcomes at a large integrated health maintenance organization with flagship centers in the United States.

OBJECTIVE: To determine if patients undergoing microvascular reconstructive head and neck surgery (MRHNS) at a large integrated health maintenance organization can expect outcomes similar to some of the best or flagship centers in the United States. DESIGN: Outcomes (flap loss, mortality, length of stay), eligibility (recent consecutive US center experience), high-experience (100 cases), high-volume (26 cases per year), and flagship criteria were prospectively defined. A systematic MEDLINE search identified 17 eligible reports. Independent, blinded medical reviewers identified 5 centers (29%) as flagship centers. PATIENTS: The first 116 consecutive patients (average, 39 cases per year) who underwent MRHNS on this service. RESULTS: All 5 flagship centers are major academic health centers ranked in the top 18 "best head and neck hospitals" in the United States. Flap loss (1.7% vs 4.4% for flagship centers; range, 0.9%-8.8%) and mortality (2.6% vs 2.8% for flagship centers; range, 0.5%-6.3%) rates were not significantly different. Although lengths of stay in flagship centers were similar to each other and the literature (mean, 21.4 days; range, 20.1-22.5 days), our length of stay was significantly shorter (8.8 days, P<.001). CONCLUSION: For high-experience and high-volume centers, patients undergoing MRHNS at a large integrated health maintenance organization can expect morbidity and mortality outcomes similar to flagship centers in the United States, with shorter hospitalizations.

[Treatment of inflammatory pyodestructive processes of the oral cavity, maxillofacial area, and neck by laser and magnetic-laser exposure of the carotid sinus using the Optodan laser apparatus]. / Lechenie vospalitel'nykh gnoino-destruktivnykh protsessov rta, cheliustno-litsevoi oblasti i shei lazernym i magnoto-lazernym vozdeistviem na karotidnyi sinus s pomoshch'iu lazernogo apparata Optodan.

This paper presents the priority original methods (patent No. 2101046, Russia) for the treatment of inflammatory pyodestructive processes in the oral cavity, maxillofacial area, and neck (odontogenic abscesses and phlegmons including those complicated by mediastinitis and sepsis), sinusitis, carbuncles and furuncles of face and neck skin, parotitis, sialadenitis, adenophlegmons, lymphadenitis, periotitis, alveolitis, arthritis, arthrosis of the temporomandibular joint, odontogenic and traumatic osteomyelitis, infected purulent traumas (including gunshot ones), fractures of the jaws, etc. making use of Optodan laser (patent No. 2014107, Russia) for laser and magnetic-laser therapy.