Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association.

Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.

Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy.

OBJECTIVE: Left vertebral artery revascularization is indicated in surgery involving zone 2 of the aortic arch and is typically accomplished indirectly via subclavian artery revascularization. For aberrant left vertebral anatomy, direct revascularization is indicated. Our objective was to compare the outcomes of direct vertebral artery revascularization with indirect subclavian artery revascularization for treating aortic arch pathology and to identify predictors of mortality. METHODS: A retrospective cohort study was conducted at a single tertiary hospital, including patients who underwent open or endovascular vertebral artery revascularization from 2005 to 2022. Those who underwent direct vertebral revascularization were compared with those who were indirectly revascularized via subclavian artery revascularization. The outcomes of interest were a composite outcome (any of death, stroke, nerve injury, and thrombosis) and mortality. Univariate logistic regression models were fitted to quantify the strength of differences between the direct and indirect revascularization cohorts. Cox regression was used to identify mortality predictors. RESULTS: Of 143 patients who underwent vertebral artery revascularization, 21 (14.7%) had a vertebral artery originating from the aortic arch. The median length of stay was 10 days (interquartile range, 6-20 days), and demographics were similar between cohorts. The incidence of composite outcome, bypass thrombosis, and hoarseness was significantly higher in the direct group (42.9% vs 18.0%, P = .019; 33.3% vs 0.8%, P < .0001; 57.1% vs 18.0%, P < .001, respectively). The direct group was approximately three times more likely to experience the composite outcome (odds ratio, 3.41; 95% confidence interval, 1.28, 9.08); similarly, this group was approximately six times more likely to have hoarseness (odds ratio, 5.88; 95% confidence interval, 2.21, 15.62). There was no significant difference in mortality rates at 30 days, 1, 3, 5, and 10 years of follow-up. Age, length of hospital stay, and congestive heart failure were identified as predictors of higher mortality. After adjusting for these covariates, the group itself was not an independent predictor of mortality. CONCLUSIONS: Direct vertebral revascularization was associated with higher rates of composite outcome (death, stroke, nerve injury, and thrombosis), bypass thrombosis and hoarseness. Patients with aberrant vertebral anatomy are at higher risks of these complications compared with patients with standard arch anatomy. However, after adjusting for other factors, mortality rates were not significantly different between the groups.

Vertebral artery dissection caused by atlantoaxial dislocation in a patient with Marfan syndrome.

A small number of case reports have documented a link between atlantoaxial dislocation (AAD) and vertebral artery dissection (VAD), but this association has never been described in patients with hereditary connective tissue disorders. We present a case of an 18-year-old female patient, diagnosed with Marfan syndrome since the age of one, who underwent brain MRA for intracranial aneurysm screening revealing tortuosity of the internal carotid and vertebral arteries as well as atlantoaxial dislocation. Since the patient was asymptomatic, a wait-and-see approach was chosen, but a follow-up MRA after 18 months showed the appearance of a dissecting pseudoaneurysm of the V3 segment of the left vertebral artery. Despite the patient being still asymptomatic, it was decided to proceed with C1-C2 stabilization to prevent further vascular complications. Follow-up imaging showed realignment of the atlantoaxial joint and reduction of the dissecting pseudoaneurysm of the left vertebral artery. In our patient, screening MRA has led to the discovery of asymptomatic arterial and skeletal abnormalities which, if left untreated, might have led to severe cerebrovascular complications. Therefore, AAD correction or close monitoring with MRA should be provided to MFS patients with this craniovertebral junction anomaly, even if asymptomatic.

Association between Bilateral Vertebral Artery Blood Flow Changes and Posterior Circulation Infarction in Patients with Severe Intracranial Stenosis.

INTRODUCTION: The objective of this study was to explore the association between net vertebral artery flow volume (NVAFV), calculated through color duplex ultrasonography, and posterior circulation infarction (PCI) in patients with severe intracranial vertebral artery (VA) stenosis. METHODS: 234 patients with severe intracranial VA stenosis (≥70%) were categorized into the PCI group (n = 139) and the non-PCI group (n = 95) based on cranial MRI diagnosis. The correlation between NVAFV and CT perfusion data was analyzed, and the occurrence of PCI under diverse PCI mechanisms was also investigated. Multifactorial logistic regression and stratified analysis was performed to analyze the association between NVAFV and PCI. Lastly, generalized additive models and smooth curve fitting was utilized to outline relationship between NVAFV and PCI. RESULTS: NVAFV showed a significant correlation with cerebral blood flow, mean transmit time, and time to peak. In the large artery atherosclerosis mechanism, a reduction in NVAFV correlated with a gradual rise in PCI cases (p = 0.002), while this trend lacked significance in the branch artery occlusive disease mechanism (p = 0.993). In the fully adjusted model, each 10 mL/min increase in NVAFV reduced PCI incidence by 11% (OR 0.890, 95% CI 0.840-0.943, p < 0.001), Sensitivity analysis showed similar results; NVAFV presented different PCI risks among various glucose level subgroups, the OR (95% CI) for PCI was 0.788 (0.684, 0.906) in low-glucose group (T1), 0.968 (0.878, 1.066) in moderate-glucose group (T2), and 0.886 (0.801, 0.979) in high-glucose group (T3). Smooth curve fitting demonstrated a linear negative association between NVAFV and PCI. CONCLUSION: NVAFV demonstrated an association with PCI in patients with severe intracranial VA stenosis, it can serve as a reference for identifying high-risk populations of PCI; however, it must be considered in combination with glucose.

Bow hunter's syndrome due to an anomalous right vertebral artery origin and contralateral absence: a case report and literature review.

BACKGROUND: Bow Hunter's syndrome (BHS), also known as rotational vertebral artery occlusion (RVAO), is a rare condition characterized by dynamic vertebrobasilar insufficiency due to position-dependent occlusion of the vertebral artery (VA). In the existing literature, most cases of BHS are attributed to osteophytic compression originating from the occipital condyle or within the transverse foramen, often accompanied by anatomical abnormalities of the VA. However, cases presenting solely with VA anomalies in the absence of any cervical vertebral structural abnormality are rare. This case report presents a unique instance of BHS in a 56-year-old male, attributed to the anomalous origin of the right VA and the absence of the left VA, without cervical structural abnormalities. CASE PRESENTATION: The patient exhibited symptoms like episodic dizziness and vertigo, which were exacerbated by rightward head rotation and alleviated upon returning to a neutral position. Diagnostic evaluation, including digital subtraction angiography, revealed that the right VA originated from the right common carotid artery and compression-induced stenosis of the right VA during head rotation. Conservative management, including avoidance of certain head movements and anti-arteriosclerosis medication, led to symptom resolution over a two-year follow-up period. CONCLUSIONS: This report contributes to the understanding of BHS by highlighting a rare vascular anomaly presentation and incorporates a review of 14 similar case reports in the literature describing that an anatomical abnormality of the VA is mainly responsible for the pathology of BHS in the absence of cervical vertebral anomalies, thus emphasizing the need for careful diagnostic and management strategies.

Association of diabetes and white blood cell count with stroke in patients with carotid artery dissection.

BACKGROUND: Carotid artery dissection is an important cause of stroke. However, the predictors of ischemic stroke in patients with carotid artery dissection are controversial. The study aimed to analyze the predictors of ischemic stroke in patients with carotid artery dissection through retrospective medical records. METHODS: Data of discharged patients diagnosed with carotid artery dissection during 2019-2023 were retrospectively collected. Based on the occurrence of ischemic stroke, the patients were divided into the ischemic stroke or non-ischemic stroke groups. Based on the results of univariate analyses, variables with an associated P value < 0.05 were introduced into the multivariable logistic regression analysis. . RESULTS: A total of 165 patients were included in the study, with an average age of 55.00 (48.00, 66.00) years, including 86 patients with internal carotid artery dissection and 79 patients with vertebral artery dissection. Ischemic stroke occurred in 69 patients with carotid artery dissection. Multivariate logistic regression analysis indicated that diabetes (odds ratio [OR]: 3.144, 95% confidence interval [CI]: 1.552-6.508, P<0.002) and high white blood cells count (OR: 1.157, 95% CI: 1.02-1.327,P = 0.028) were related to the incidence of ischemic stroke in patients with carotid artery dissection. CONCLUSION: Ischemic stroke caused by carotid artery dissection causes severe damage to the nervous system. This study found that diabetes and high white blood cells count were associated with the incidence of ischemic stroke in patients with carotid artery dissection. Therefore, monitoring and controlling blood glucose levels and infections is essential in patients with carotid artery dissection to reduce the incidence of stroke.

Cervical anterior spinal artery infarction associated with anomalous vertebral artery: a case report.

We report a unique case of cervical anterior spinal artery (ASA) infarction in a 49-year-old male with hypercholesterolemia and sleep apnea. The patient experienced sudden cervical pain, quadriparesis, areflexia, and urinary incontinence after swallowing a large food bolus. Imaging revealed an infarction at the C3-C5 levels and an anomalous right vertebral artery (VA) originating from the thoracic aorta, tightly enclosed between the aorta and a vertebral column with an anterior osteophyte. This aberrant VA was the primary vascular supply to the ASA, with no contribution from the left VA or supreme intercostal arteries. We propose that transient injury to the right VA, induced by compression between the aortic arch, the food bolus, and the osteophyte, led to temporary hypoperfusion of the ASA, causing a watershed ischemic injury in the mid cervical cord's anterior gray matter. The article also provides an in-depth discussion of the developmental and clinical characteristics associated with this rare vascular anomaly.

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.

Iatrogenic vertebral artery injury during catheter ablation treated using coil embolization.

The internal jugular vein (IJV) is occasionally used for blood access during catheter ablation. Additionally, accidental injury of the vertebral artery during an IJV puncture is a rare complication that can result in catastrophic events, such as death. However, vascular access complications cannot be completely prevented despite the introduction of ultrasound-guided punctures. Here, we present a case of a patient with symptomatic paroxysmal atrial fibrillation that required catheter ablation.

Surgical approach through the anterior scalene muscle resection for invasive tumours in the supraclavicular fossa (with video).

BACKGROUND: The supraclavicular fossa contains many vital organs to be preserved, such as the brachial plexus, subclavian artery and vertebral artery. Various surgical methods have been reported. However, no well-standardized surgical procedure has been established. METHODS: Between 2010 and 2020, we performed 28 surgical treatments of the superior mediastinum and supraclavicular fossa. Of these, we retrospectively reviewed seven cases of supraclavicular invasion using a unified surgical technique in which the anterior scalene muscle was resected, and the inter-scalene triangle was approached. RESULTS: We performed claviculectomy in four cases and a transmanubrial approach in three cases. In all cases, by resecting the anterior scalene muscle, the brachial plexus, subclavian artery and vertebral artery were preserved. There were no critical postoperative complications other than tracheostomy and lymphatic leakage. Median bleeding amount and operative time were 438 (range; 76-1144) ml and 328 (range; 246-615) minutes, respectively. CONCLUSIONS: The anterior scalene muscle resection method might be a safe and standardized method for preserving the brachial plexus, subclavian artery and vertebral artery.

Lateral atlanto-axial joint access using the C2 pedicle.

BACKGROUND: Neck pain and headaches can arise from the lateral atlanto-axial joint (LAA joint). This pain can be diagnosed with intra-articular injections of local anesthetic. A widely used technique for access to the lateral atlanto-axial joint uses a posterior approach, but this approach can be hazardous because of the proximity of the vertebral artery, the dural sac, and the C2 spinal nerve and dorsal root ganglion. OBJECTIVE: The objective was to describe and test a new technique for accessing the LAA joint that avoids structures that lie behind the joint. INTERVENTIONS: The new technique was described, and tested for tolerance in 10 patients with unilateral suboccipital pain, and tenderness over the LAA joint, along with evidence of LAA joint arthropathy on SPECT CT. The technique requires inserting a needle along a trajectory tangential to the dorsal surface of the C2 lamina. It involves obtaining a declined view of the C2 lamina and C2 pedicle. CONCLUSIONS: In all cases, the C2 pedicle was easily identified and allowed the needle to pass asymptomatically underneath the neurovascular structures behind the joint. The tactile response of the lamina of C2 provided important feedback regarding needle depth caudal to the LAA joint.

Relationship between serum endothelin-1 and in-stent restenosis following vertebral artery stenting.

The study objective was to investigate the relations between serum endothelin-1 and in-stent restenosis in vertebral artery stenting. Sixty-eight patients undergoing re-examination of vertebral artery stenting in the Department of Cerebrovascular Disease, Hangzhou Third People's Hospital, between April 2019 and October 2022, were invited to participate. According to the presence of vertebral artery stenting, patients were divided into the restenosis (n = 19) or non-restenosis (n = 49) groups. General clinical data and endothelin-1 levels were compared between the groups. Logistic regression analysis was used to explore the relations between endothelin-1 level and risk for in-stent restenosis. Receiver operating characteristic curves were drawn to test the diagnostic value of serum endothelin-1 level for in-stent restenosis. Compared with the non-restenosis group, restenosis group levels of low-density lipoprotein, triglycerides, and endothelin-1 were significantly higher (p < 0.05) Multivariate logistic regression analysis showed that endothelin-1, stent length, and low-density lipoprotein were independently associated with in-stent restenosis (odds ratio = 1.502, 95% confidence interval: 0.042 ~ 0.212, p = 0.000; odds ratio = 1.899, 95% confidence interval: 1.116 ~ 2.237, p = 0.000; odds ratio = 1.899, 95% confidence interval: 1.228 ~ 3.337, p = 0.001, respectively). Area under the curve for serum endothelin-1 in the diagnosis of vertebral artery in-stent restenosis was 0.938. The best diagnostic cut-off value was 11.94 ng/L. Sensitivity was 89.5%. Specificity was 85.7%. These cumulative data indicate that endothelin-1 level is independently associated with in-stent restenosis.

Bilateral Hunter's bow syndrome: a rare case diagnosed by dynamic digital subtraction angiography.

A 27-year-old female patient suffered from recurrent episodes of dizziness, visual rotation, and intermittent right-hand numbness over one month. Symptoms persisted and were triggered by rotating the head to the right or left for more than 10 seconds. Neurological examination showed that the symptoms were most pronounced when the head was rotated over 45 degrees to the right. Dynamic digital subtraction angiography (dDSA) was performed to confirm the diagnosis. Leftward head rotation caused occlusion of the right vertebral artery(VA) . However, the symptoms were mild, owing to sufficient compensation by the right posterior communicating artery (PCA) . Rightward head rotation exceeding 45 degrees resulted in occlusion of the left VA. The resultant symptoms were pronounced due to inadequate compensation of the left PCA. CT angiographic reconstruction showed bilateral vertebral arteries with tortuous loops of vessels at the level of the C2 vertebrae . CT images showed no cleavage between the left VA and the anterior surface of the left C2 transverse foramen. Conservative treatment was recommended considering the patient's young age and limited severity of her symptoms. Bow Hunter's syndrome is a rare neurovascular disorder characterized by dynamic occlusion of the VAs during head rotation, leading to inadequate blood flow to the posterior cerebral circulation. Bow hunter syndrome, where bilateral dynamic occlusion occurs without a discernible dominant side of the VA, is uncommon. The medical community must acknowledge cervical vertigo as a distinct disorder. dDSA remains the gold standard for its diagnosis.

Characterization of posterior circulation blood perfusion in patients with different degrees of basilar artery tortuosity.

OBJECTIVE: The morphology of basilar artery (BA) may affect posterior circulation blood perfusion. We aimed to investigate whether different degrees of BA tortuosity could lead to the alterations of posterior circulation perfusion. METHODS: We collected 138 subjects with different BA tortuosity scores, including 32 cases of score 0, 45 cases of score 1, 43 cases of score 2, and 18 cases of score 3. A higher score represented a higher degree of BA tortuosity. Ordered logistic regression analysis was performed to investigate the risk factors for BA tortuosity. We quantitatively measured the cerebral blood flow (CBF) in eight posterior circulation brain regions using arterial spin labeling. SPSS 25.0 was used for statistical analysis. The correlation between the CBF and BA tortuosity was corrected by the Bonferroni method. The significance level was set at 0.006 (0.05/8). RESULTS: Hypertension (HR: 2.39; 95%CI: 1.23-4.71; P = 0.01) and vertebral artery dominance (HR: 2.38; 95%CI: 1.10-4.67; P = 0.03) were risk factors for BA tortuosity. CBF in occipital gray matter (R = -0.383, P < 0.001), occipital white matter (R = -0.377, P < 0.001), temporal gray matter (R = -0.292, P = 0.001), temporal white matter (R = -0.297, P < 0.001), and cerebellum (R = -0.328, P < 0.001) were negatively correlated with BA tortuosity degree. No significant correlation was found between the BA tortuosity degree and CBF in hippocampus (R = -0.208, P = 0.014), thalamus (R = -0.001, P = 0.988) and brainstem (R = -0.204, P = 0.016). CONCLUSIONS: BA tortuosity could affect posterior circulation blood perfusion. CBF was negatively correlated with BA tortuosity degree. The morphology of BA may serve as a biomarker for posterior circulation and the severity of posterior circulation ischemia.

High risk and low prevalence diseases: Spontaneous cervical artery dissection.

INTRODUCTION: Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications. CONCLUSIONS: An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Neurovascular considerations in patients with Down syndrome and moyamoya syndrome.

In this article, we describe a rare and complex case of moyamoya syndrome in a 7-year-old boy with Down syndrome and atlantoaxial subluxation. The patient presented with an ischemic stroke in the left hemisphere and cervical cord compression with increased cord edema. Diagnostic digital subtraction angiography revealed unique patterns of vascular involvement, with retrograde flow through the anterior spinal artery, ascending cervical artery, occipital artery, and multiple leptomeningeal arteries compensating for bilateral vertebral artery occlusion. This case underscores the underreported phenomenon of upward retrograde flow through the anterior spinal artery in bilateral vertebral artery occlusion. We address the rare manifestation of posterior circulation involvement in moyamoya syndrome, highlighting the importance of considering atlantoaxial instability as a contributing factor, as the absence of atlantoaxial stability is a risk factor for vertebral artery dissection. This study contributes valuable insights into the intricate relationship of moyamoya syndrome, Down syndrome, and atlantoaxial instability, urging clinicians to consider multifaceted approaches in diagnosis and treatment. It also emphasizes the potential significance of the anterior spinal artery as a compensatory pathway in complex vascular scenarios.

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.

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.

Unilateral high-riding vertebral artery is associated with asymmetric morphological changes of the atlantoaxial joint: a novel risk factor for atlantoaxial osteoarthritis.

PURPOSE: This study aimed to investigate the association between unilateral high-riding vertebral artery (HRVA) and morphological changes in the atlantoaxial joint (AAJ) and to determine whether unilateral HRVA is a risk factor for atlantoaxial osteoarthritis (AAOA). METHODS: We conducted a retrospective analysis of 2496 patients admitted to our medical center between January 2020 and December 2022 who underwent CT imaging of the cervical spine. Two hundred and seventy-two patients with unilateral HRVA (HRVA group) were identified and a respective 2:1 age- and sex-matched control group without HRVA was built. Morphological parameters, including C2 lateral mass settlement (C2 LMS), C1/2 coronal inclination (C1/2 CI), lateral atlanto-dental interval (LADI), and C1/2 relative rotation angle (C1/2 RRA) were measured. The degree of AAOA was recorded. Risk factors associated with AAOA were identified using univariate and multivariable logistic regression analyses. RESULTS: The study included 61.4% women, and the overall average age of the study population was 48.7 years. The morphological parameters (C2 LMS, C1/2 CI, and LADI) in AAJ were asymmetric between the HRVA and the non-HRVA sides in the HRVA group (p < 0.001). These differences in parameters (d-C2 LMS, d-C1/2 CI, and d-LADI) between the HRVA and the non-HRVA sides, and C1/2 RRA were significantly larger than those in the control group. Eighty-three of 816 patients (10.2%) with AAOA had larger values of d-C2 LMS, d-C1/2 CI, d-LADI, and C1/2 RRA compared with the patients without AAOA (p < 0.05). The multivariable logistic regression analysis indicated that unilateral HRVA [adjusted odds ratio (OR) = 2.6, 95% CI: 1.1-6.3, p = 0.029], age in the sixth decade or older (adjusted OR = 30.2, 95% CI: 16.1-56.9, p < 0.001), women (adjusted OR = 2.1, 95% CI: 1.0-5.6, P = 0.034) were independent risk factors for AAOA. CONCLUSION: Unilateral HRVA was associated with asymmetric morphological changes of nonuniform settlement of C2 lateral mass, lateral slip of atlas, and atlantoaxial rotation displacement. Besides age ≥ 60 years and females, unilateral HRVA is an independent risk factor for AAOA.

Far lateral approach for dumbbell-shaped C1 schwannomas: how I do it.

BACKGROUND: Dumbbell-shaped C1 schwannomas are rare lesions that involve both intra- and extradural compartments. Because of the intimate relationships these lesions develop with the third and fourth segments of the vertebral artery, surgical removal of these lesions remains a challenge. METHOD: We describe the key steps of the far lateral approach for dumbbell-shaped C1 schwannomas with a video illustration. The surgical anatomy is described along with the techniques for protecting the vertebral artery. CONCLUSION: Dumbbell-shaped C1 schwannomas can be safely removed by using the far lateral approach, surgical anatomy expertise, and intraoperative microvascular Doppler.