Occipital artery to vertebral artery bypass for treatment of bilateral vertebral artery occlusion with QMRA as an adjunct to diagnostic assessment.

PURPOSE: Stroke, the second leading cause of death globally, often involves ischemia in the vertebrobasilar territory. This condition is underexplored, despite significant morbidity and mortality risks. The purpose of this study is to present a case of occipital artery to V3 segment vertebral artery bypass, emphasizing the role of quantitative magnetic resonance angiography (qMRA) in assessing flow and guiding surgical intervention. METHODS: A 66-year-old man with bilateral vertebral artery occlusion presented acute symptoms. qMRA was employed to evaluate flow dynamics and determine the feasibility of a flow augmentation bypass surgery. The occipital artery to left vertebral artery bypass (OA-to-VA) was performed, utilizing an inverted hockey-stick incision and an antegrade inside-out technique. The patency of the bypass was confirmed using both Doppler probe and Indocyanine green. RESULTS: Postoperative assessments, including computed tomography angiography (CTA) and qMRA, demonstrated the patency of the bypass with improved flow in the basilar artery and left vertebral artery. The patient's condition remained stable postoperatively, with residual peripheral palsy of the left facial nerve. CONCLUSION: In conclusion, the presented case illustrates the efficacy of the OA-to-VA bypass in addressing symptomatic bilateral vertebral artery occlusion. The study underscores the pivotal role of qMRA in pre- and postoperative assessments, providing noninvasive flow quantification for diagnostic considerations and long-term follow-up in patients with vertebrobasilar insufficiency.

Bridge-layered decompression technique for vertebral artery-involved hemifacial spasm: technical note.

BACKGROUND: Hemifacial spasm (HFS) is most effectively treated with microvascular decompression (MVD). However, there are certain challenges in performing MVD for HFS when the vertebral artery (VA) is involved in compressing the facial nerve (VA-involved). This study aimed to introduce a "bridge-layered" decompression technique for treating patients with VA-involved HFS and to evaluate its efficacy and safety to treat patients with HFS. METHODS: A single-center retrospective analysis was conducted on the clinical data of 62 patients with VA-involved HFS. The tortuous trunk of VA was lifted by a multi-point "bridge" decompression technique to avoid excessive traction of the cerebellum and reduce the risk of damage to the facial-acoustic nerve complex. To fully decompress all the responsible vessels, the branch vessels of VA were then isolated using the "layered" decompression technique. RESULTS: Among the 62 patients, 59 patients were cured immediately after the surgery, two patients were delayed cured after two months, and one had occasional facial muscle twitching after the surgery. Patients were followed up for an average of 19.5 months. The long-term follow-up results showed that all patients had no recurrence of HFS during the follow-up period, and no patients developed hearing loss, facial paralysis, or other permanent neurological damage complications. Only two patients developed tinnitus after the surgery. CONCLUSION: The "bridge-layered" decompression technique could effectively treat VA-involved HFS with satisfactory safety and a low risk of hearing loss. The technique could be used as a reference for decompression surgery for VA-involved HFS.

[Anatomical Variations to the Vertebral Artery and Posterior Inferior Cerebellar Artery are Associated with the Partial Persistence of Primitive Lateral Basirovertebral Anastomosis].

The angioarchitecture of the hindbrain is homologous to that of the spinal cord, and its vascular system can be analyzed at the longitudinal and axial structures. During embryonic development, there are two main longitudinal arteries: the longitudinal neural artery and the primitive lateral basilovertebral anastomosis. Commonly observed variations are formed by the fenestration and duplication of either the vertebrobasilar artery, or cerebellar artery, which can be observed when the primitive lateral basilovertebral anastomosis partially persists. Understanding the pattern and development of blood supply to the hindbrain provides useful information of various anomalies in the vertebrobasilar junction and cerebellar arteries.

[Perfusion Methods and Reconstruction Techniques for Performing Aortic Arch Surgery with Isolated Left Vertebral Artery].

In our institution, when we perform aortic arch surgery with isolated left vertebral artery using an extracorporeal circulation, we select an interposed saphenous vein graft technique. This technique has a relatively short clamping time and allows for selective cerebral perfusion and flexible choice of reconstruction site. Although other techniques, such as an island reconstruction, have been reported, we do not perform it often due to its longer ischemic time of the left vertebral artery. On the other hand, we use a direct reconstruction technique in cases where an extracorporeal circulation is not used. This direct reconstruction technique in cases of isolated left vertebral artery could reduce the time and number of clamping it.

Ruptured aneurysm in collateral arteries with blood-flow impairment of posterior inferior cerebellar artery: a report of three cases.

Herein, we report three cases of cerebellar hemorrhage due to a ruptured small aneurysm located on a collateral artery compensating for one or more stenotic or occluded major cerebellar arteries. In each case, endovascular distant parent artery occlusion of both the collateral artery and aneurysm was performed to prevent rebleeding. A ruptured small aneurysm in a collateral artery may be observed in patients with hemorrhage in an atypical cerebellar region, especially in cases of stenosis or occlusion of the vertebral artery or posterior inferior cerebellar artery. Thus, cerebral angiography is recommended to rule out collateral artery aneurysm.

Hybrid surgery of vertebral artery transposition combined with scallop and fenestration technique for the repair of type B aortic dissection patient with isolated left vertebral artery: A case report.

RATIONALE: Acute type B aortic dissection (ABAD) is a fatal cardiovascular disease with high morbidity and mortality. Isolated left vertebral artery (ILVA) is a rare aortic arch mutation originating from the aortic arch. The simultaneous occurrence of both increases the complexity and difficulty of thoracic endovascular aortic repair. However, there have been few reports on the recommendation of thoracic endovascular aortic repair treatment strategies for aortic dissection patients concomitant ILVA with insufficient landing zone. Here, we report a case of ABAD combined with ILVA treated with hybrid surgery of left vertebral artery transposition alliance with Scallop and in vivo fenestration endograft. PATIENT CONCERNS: A 38-year-old middle-aged man was transferred to our vascular department with persistent pain in his lower abdomen for 8 hours. DIAGNOSES: Preoperative computed tomography angiogram of the thoracic and abdominal aorta diagnosed with ABAD accompanied with ILVA. INTERVENTIONS: Hybrid surgery of left vertebral artery transposition alliance with Scallop and in situ fenestration endograft for revascularization of ILVA, left subclavian artery, and left common carotid artery. OUTCOMES: The hybridization operation was successfully completed. There were no complications of cerebral and spinal cord ischemia after operation. Computed tomography angiogram examination indicated no internal leakage existed in the stent and patency of the arch vessels and the transposed left vertebral artery follow-up 3 months after surgery. LESSONS: This study gave us experience in the treatment of aortic dissection with left vertebral artery variation and suggested that left vertebral artery transposition combined with scallop and in vivo fenestration stent is safe and effective.

Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Bypass versus Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for Treating Posterior Circulation Aneurysms: A Systematic Review and Comparative Meta-Analysis.

BACKGROUND: When traditional therapies are unsuitable, revascularization becomes essential for managing posterior inferior cerebellar artery (PICA) or vertebral artery aneurysms. Notably, the PICA-PICA bypass has emerged as a promising option, overshadowing the occipital artery-PICA (OA-PICA) bypass. The objective was to compare the safety and efficacy of OA-PICA and PICA-PICA bypasses. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review and meta-analysis to evaluate the safety and efficacy of OA-PICA and PICA-PICA bypasses for treating posterior circulation aneurysms. RESULTS: We analyzed 13 studies for the PICA-PICA bypass and 16 studies on the OA-PICA bypass, involving 84 and 110 patients, respectively. The median average follow-up for PICA-PICA bypass was 8 months (2-50.3 months), while for OA-PICA, it was 27.8 months (6-84 months). The patency rate for OA-PICA was 97% (95% confidence interval [CI]: 92%-100%) and 100% (95% CI: 95%-100%) for PICA-PICA. Complication rates were 29% (95% CI: 10%-47%) for OA-PICA and 12% (95% CI: 3%-21%) for PICA-PICA. Good clinical outcomes were observed in 71% (95% CI: 52%-90%) of OA-PICA patients and 87% (95% CI: 75%-100%) of PICA-PICA patients. Procedure-related mortality was 1% (95% CI: 0%-6%) for OA-PICA and 1% (95% CI: 0%-10%) for PICA-PICA. CONCLUSIONS: Both procedures have demonstrated promising results in efficacy and safety. PICA-PICA exhibits slightly better patency rates, better clinical outcomes, and fewer complications, but with a lack of substantial follow-up and a smaller sample size. The choice between these procedures should be based on the surgeon's expertise and the patient's anatomy.

Surgical management of tumors of the cervical spine and craniovertebral junction involving the vertebral artery: A narrative review.

BACKGROUND: The vertebral artery (VA) is in close proximity to bony structures, nerves and nerve sheaths of the cervical spine and craniovertebral junction (CVJ). These structures can be sources of tumors that are responsible for displacement, encasement and sometimes invasion of the VA. Removing these tumors while minimizing the risk of vascular injury requires thorough knowledge of the vascular anatomy, risk factors of vascular injury, the relationships of each tumor type with the VA, and the different surgical approaches and techniques that result in the best outcomes in terms of vascular control, tumoral exposure and resection. OBJECTIVE: To present an overview of preoperative and anatomical considerations, differential diagnoses and various approaches to consider in cases of tumors in close relationship with the VA. METHOD: A review of recent literature was conducted to examine the anatomy of the VA, the tumors most frequently affecting it, surgical approaches, and the necessary pre-operative preparations for ensuring safe and maximal tumor resection. This review aims to underscore the principles of treatment. CONCLUSION: Tumors located at the CVJ and the cervical spine intimately involved with the VA, pose a surgical challenge and increase the risk of incomplete removal of the lesion. Detailed knowledge of the patient-specific anatomy and a targeted pre-operative work-up enable optimal planning of surgical approach and management of the VA, thereby reducing surgical risks and improving extent of resection.

[Preoperative Simulation for Complication Control in Spinal Surgery].

The craniovertebral junction not only contains anatomically important structures such as the medulla oblongata, upper cervical spinal cord, and vertebral artery, but also controls the dynamic movements of flexion, extension, and rotation of the head and neck. Consequently, instability and spinal deformities can easily occur in the craniovertebral region, and appropriate treatment should be selected based on the specificity of the lesion. Basilar invagination often involves bone and vascular anomalies and fusion surgery is often required. Therefore, careful pre-operative simulations are necessary. The creation and use of three-dimensional bone models, including image navigation, are useful for surgical simulation.

Effects and safety of endovascular recanalization for non-acute symptomatic intracranial vertebral artery occlusion with different risks.

There is no consensus on the optimal treatment for non-acute symptomatic intracranial vertebral artery occlusion, and endovascular recanalization is a challenging procedure. We report our clinical experience of endovascular recanalization in patients with non-acute symptomatic intracranial vertebral artery occlusion to assess the feasibility and safety of endovascular recanalization and determine the candidate patients for this procedure. Ninety-two patients with non-acute symptomatic intracranial vertebral artery occlusion who underwent endovascular recanalization from January 2019 to December 2021 were retrospectively analyzed. we grouped all patients according to imaging examination findings, occlusion length, duration, nature, calcification, and angulation to evaluate the risk of endovascular recanalization. The overall success rate of endovascular recanalization was 83.7% (77/92), and the perioperative complication rate was 10.9% (10/92). Among the 3 classification groups, the recanalization success rate gradually decreased from the low-risk group to the high-risk group (low-risk: 100%, medium-risk: 93.3%, high-risk group: 27.8%, P = .047), while the overall perioperative complication rate showed the opposite trend (0%, 10.0%, 38.9%, respectively, P = .001); the proportion of patients with 90-day modified Rankin Scale scores of 0-2 decreased successively (100%, 83.3%, and 22.2%, respectively, P < .026); 77 patients with successful recanalization were followed; the rate of restenosis/reocclusion increased sequentially (0%, 17.9%, and 80%, respectively, P = .000). Patients in the low- and medium-risk groups showed a good clinical course after endovascular recanalization. Among 88 patients (four patients lost to follow-up), with a median clinical follow-up of 13 months (interquartile range », 7-16), the rate of stroke or death after 30 days was 17.4% (16/92). Endovascular recanalization is safe and feasible for low- and medium-risk patients with non-acute symptomatic intracranial vertebral artery occlusion; it is also an alternative to conservative therapy for the patients.

Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch.

The study aimed to provide physician modified fenestration (PMF) on a single-branched stent for the aortic arch (Castor) to protect the isolated left vertebral artery (ILVA) during thoracic endovascular aortic repair (TEVAR). Patients who underwent TEVAR involving ILVA reconstruction through PMF performing on the Castor branched stent were included in a retrospective, multi-centre study from June 2018 to December 2022. In these patients, all proximal landing zones of "Castor" were positioned in Ishimaru zone 2a. A total of twenty-five patients met the inclusion criteria and the achievement rate showed 25/25 (100%) success in them. The twenty-five patients had a median follow-up length of 28.5 ± 14.6 months. One patient (4.0%) suffered from postoperative ischemic stroke before discharge. One patient (4.0%) died from a hemodialysis-related brain hemorrhage before discharge on the 29th day after the procedure. One patient died of advanced liver cancer in the 33th month after discharge. Aortic rupture, stroke or spinal cord injury did not occur throughout the follow-up period after discharge. Two patients (8.0%) experienced endoleak at the fenestration, however, resulting in only one's necessity for reintervention. Notably, the procedure effectively maintained ILVAs patency for all patients during follow up. According to our preliminary findings, performing a TEVAR under local anaesthesia using PMF on a Castor branched stent for ILVA preservation appeared practical, secure, and effective.

A comprehensive review of the vertebral artery anatomy.

BACKGROUND: The vertebral arteries (VA) play a critical role by supplying nearly one-third of the brain's blood flow, predominantly contributing to the posterior circulation. These arteries may need to be exposed in a various cranial and cervical procedures and offers access to investigate or treat vascular lesions by endovascular means related to the posterior circulation. Given its complex anatomy, which is subject to numerous variations, and its role in supplying vital brain regions, a thorough understanding of the VA's anatomy is paramount for any related procedure. OBJECTIVE: To provide a comprehensive overview of vertebral artery anatomy and its relevance in contemporary clinical practice. METHODS: Dissection of the entire vertebral artery length using cadaveric specimen, combined with a comprehensive literature review. RESULTS: The vertebral artery can be subdivided into four segments. Each of these segments has its own unique topographic anatomy with its variations, anastomoses, and significance in surgery. CONCLUSION: As surgical and endovascular techniques continue to evolve with technological improvements, we are now more equipped than ever to manage complex lesions involving the VA. However, with its increasingly complexity comes the necessity for a deeper and more comprehensive understanding of the VA. Possessing the detailed knowledge of the VA is vital for the successful execution of any procedure involving it.

Applied anatomy of the vertebral arteries for endovascular neurointerventions.

The vertebral arteries (VAs) constitute most of the arterial supply to the posterior cerebral vascular circulation. They have anatomical specificities and may have variants that are critical for neurointerventionists to recognize in order to design open or endovascular surgical treatment. This review addresses each segment of the VA including its origin and discusses the branches and relevant anatomical features for neurointerventions.

Spontaneous intracranial vertebral artery dissections presenting with subarachnoid hemorrhage.

BACKGROUND: Vertebral artery dissection (VAD) is an infrequent source of subarachnoid hemorrhage (SAH), with a high mortality rate, primarily due to the risk of rebleeding both before and after medical intervention. This paper provides a comprehensive analysis of the anatomy, pathophysiology, clinical presentation, treatment strategies, and outcomes of intracranial vertebral artery dissections that result in subarachnoid hemorrhage. METHODS: Comprehensive five-year literature review (2018-2022) and a retrospective analysis of patient records from our institution between 2016 and 2022. We included studies with a minimum of 5 patients. RESULTS: The study incorporated ten series from the literature and 22 cases from CHUM. Key anatomical factors increasing the risk of VAD include the vertebral artery's origin from the aortic arch, asymmetry of the vertebral artery, and its tortuosity. Patients may display specific collagen and genetic abnormalities. The occurrence of VAD appears to be more prevalent in men. Those with a ruptured intracranial VAD typically show prodromal symptoms and present with severe SAH. Rebleeding within the first 24 h is frequent. While standard imaging methods are usually adequate for VAD diagnosis, they may not provide detailed information about the perforator anatomy. Treatment approaches include both deconstructive and reconstructive methods. CONCLUSION: Ruptured VAD is a critical, life-threatening condition. Many patients have a poor neurological status at presentation, and rebleeding prior to treatment is a significant concern. Deconstructive techniques are most effective in preventing rebleeding, whereas the efficacy of reconstructive techniques needs more investigation.

Vertebral artery stenosis from osteophyte: A systematic review and case series.

BACKGROUND: Rotational vertebral artery syndrome, also referred to as Bow Hunter's syndrome (BHS), manifests when the vertebral artery (VA) is compressed following head rotation. This compression is often caused by an osteophyte and may lead to symptoms of a posterior stroke. This systematic review aims to shed light on the current management strategies for BHS resulting from osteophytes. Additionally, we present two illustrative cases where the VA compression by an osteophyte was effectively resolved by complete resection of the problematic bone spur. METHODS: A literature search was conducted across Embase, PubMed and Medline in September 2023. Keywords related to vertebral artery [MESH], vertebrobasilar insufficiency [MESH] and osteophyte [MESH] were the focus of this review. Risk of bias in retained studies was assessed using the Joanna Briggs Institute Critical Appraisal tools for Qualitative Research. A narrative synthesis of our findings is presented. RESULTS: A total of 30 studies were included in this review. Vertigo was the most reported symptom by patients (n = 16). On imaging, the VA was often compressed at C4-5 (n = 10) and C5-6 (n = 10) with no evident side predominance observed. Anterior cervical discectomy and fusion (ACDF, n = 13) followed by anterior decompression without fusion (n = 8) were the most performed surgical procedures to manage BHS. CONCLUSION: Surgical decompression of the VA is a safe and effective intervention for patients experiencing symptomatic osteophytic compression during head rotation. This procedure restores normal vascular function and reduces the risk of ischemic events. This review highlights the importance of timely diagnosis and intervention in such cases.

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.

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.

Posterior Inferior Cerebellar Artery Aneurysm Shaped Like a "Calabash Gourd" and Mimicking a Tumor.

Posterior inferior cerebellar artery aneurysms are likely to be fusiform, yet they hardly enlarge to mimic a tumor in the posterior fossa on radiology. They constitute about 3%-4% of all cerebral aneurysms. A 65-year-old woman presented with tremor in her right upper limb for 1 year and intermittent dizziness for 8 months. Interestingly, magnetic resonance imaging revealed 2 unanimously enhanced masses like mother and daughter located in the right cerebellum hemisphere. The lesion was resected via surgery, and histopathology established the diagnosis of an aneurysm. Her tremor and dizziness subsided 3 months after the surgery, and at her 2-year follow-up she was well with no further neurologic deficits.

Transcervical Vertebral Artery Origin Endarterectomy for Vertebrobasilar Insufficiency.

Vertebral artery (VA) stenosis is a cause of vertebrobasilar insufficiency (VBI) and disabling posterior circulation stroke,1 accounting for up to 30% of all strokes.2 Although the natural history of VBI is not as well delineated as that of carotid stenosis, strokes in the basilar circulation can be more disabling than their anterior circulation counterparts. Stenosis exceeding 30% at the origin of the vertebral artery is associated with increased risk of stroke.3 The authors present a case of a female patient with significant peripheral vascular disease who presented with concerns for VBI. The patient was on antiplatelet and anticoagulative medications and a statin at the time of her presentation. Angiography demonstrated bilateral vertebral artery origin stenosis. The left VA was diminutive and arose directly from the arch (Video 1). The right VA demonstrated critical stenosis at its origin. Attempts at endovascular access of the right VA for placement of a balloon-mounted stent were unsuccessful. The patient underwent a transcervical approach for endarterectomy of the VA origin. The VA can be readily accessed using a small supraclavicular incision to isolate the V1 segment of the vessel. The procedure was performed with the patient heparinized and on antiplatelet medications. Alternatives to this strategy include patch grafting in addition to the endarterectomy or use of a short vein graft to bypass the stenosis of the VA beyond the stenotic segment.