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.

Behavior of Extracranial-to-Intracranial Extended Arterial Dissections of the Vertebral Artery.

BACKGROUND: Vertebral artery dissections (VADs) may extend from the extracranial to the intracranial vasculature (e+iVAD). We evaluated how the characteristics of e+iVAD differed from those of intracranial VAD (iVAD). METHODS AND RESULTS: From 2002 to 2019, among consecutive patients with cervicocephalic dissection, those with iVAD and e+iVAD were included, and their clinical characteristics were compared. In patients with unruptured dissections, a composite clinical outcome of subsequent ischemic events, subsequent hemorrhagic stroke, or mortality was evaluated. High-resolution magnetic resonance images were analyzed to evaluate intracranial remodeling index. Among 347 patients, 51 (14.7%) had e+iVAD and 296 (85.3%) had iVAD. The hemorrhagic presentation occurred solely in iVAD (0.0% versus 19.3%), whereas e+iVAD exhibited higher ischemic presentation (84.3% versus 27.4%; P<0.001). e+iVAD predominantly presented steno-occlusive morphology (88.2% versus 27.7%) compared with dilatation patterns (11.8% versus 72.3%; P<0.001) of iVAD. The ischemic presentation was significantly associated with e+iVAD (iVAD as a reference; adjusted odds ratio, 3.97 [95% CI, 1.67-9.45]; P=0.002]). Patients with unruptured VAD showed no differences in the rate of composite clinical outcome between the groups (log-rank, P=0.996). e+iVAD had a lower intracranial remodeling index (1.4±0.3 versus 1.6±0.4; P<0.032) and a shorter distance from dural entry to the maximal dissecting segment (6.9±8.4 versus 15.7±7.4; P<0.001). CONCLUSIONS: e+iVAD is associated with lower rates of hemorrhages and higher rates of ischemia than iVAD at the time of admission. This may be explained by a lower intracranial remodeling index and less deep intrusion of the dissecting segment into the intracranial space.

Duplication of right vertebral artery in Klippel-Feil anomaly.

The duplicated origin of the vertebral artery (VA) is an uncommon anatomical variant, which is generally identified incidentally during angiography and can be misdiagnosed as dissection in the setting of posterior circulation stroke. Here, we describe a case of the right V1 VA duplication with embryological aspects in a patient with Klippel-Feil anomaly, which was diagnosed during preoperative evaluation. Surgeons must be aware to avoid vascular injury from a duplicated VA before head-neck and spinal surgery.

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.

Delimitation of the risk area of the vertebral artery during the paramedian suboccipital approach.

OBJECTIVE: The V3 segment of the vertebral artery (V3-VA) is at risk during diverse approaches to the craniovertebral junction. Our objective is to present a system of anatomic and topographic landmarks to identify the V3-VA during the paramedian suboccipital approach (PMSOA) with the help of minimal or basic tools. MATERIAL AND METHODS: The first was a retrospective analysis of the angiotomography (CTA) of 50 patients over 18-years old, and 9 anatomical dissections. A series of lines were defined between the different bony landmarks. Within this lines the risk area of the vertebral artery (RAsV3-VA) and the risk point of the vertebral artery (RPsV3-VA) were defined. The second stage was a prospective study, where the previously defined measurements were carried out by using neuronavigation in 10 patients (20 sides) operated with the PMSO approach in order to confirm the presence of the V3 segment in the RAsV3-VA and RPsV3-VA. RESULTS: In the first stage, the V3 segment was found in the middle third of the X line in 96,6% of the cases. The distance between the inion and the UCP (percentile 5) was 20 mm and to the LCP (percentile 95) was 40 mm. In the range between the UCP and the LCP, in the middle third of the inion-mastoid line (RAsV3-VA), we found 90% of the V3-VA. The measurements taken during the second stage revealed that the artery was in the middle third of the X line in 97% of the cases. 85% of the patients presented the total of the V3s-VA on the RAsV3-VA and in 85% there was a direct relationship with the V3 segment and the RPV3s-VA. CONCLUSION: We propose an easy-to-implement system to delimit the risk area of the V3-VA during the PMSOA. We believe that these landmarks provide a practical, reliable, costless and useful tool that could decrease the risk of lesion of the V3-VA during this approach without the need of using.

Retrospective Cohort Angiographic Analysis of Vertebral Artery Dominance, Stenosis Patterns, and Demographic Correlations.

Background: Differences in dominance and stenosis in the complex vertebral artery (VA) network pose challenges in diagnosing and treating cerebrovascular diseases crucial for brain nutrition. This research examines these intricacies, highlighting the importance of detailed diagnosis and treatment methods. Objective: To analyze the prevalence of the dominant VA, evaluate the influence of gender and age on steno-occlusion, and explore the correlation between the dominant VA and stenosed VA segments. Methods: A retrospective study of 249 angiograms from patients with VA stenosed at King Abdullah University Hospital between August 2019 and December 2022. The patients presenting symptoms of vertigo, migraines, headaches, or transient ischemic attacks (TIA) were included, 182 cases were classified based on VA dominance and stenosis severity. The data were analyzed using IBM SPSS 27. Results: Out of the 182 participants, 64.8% were male, with an average age of 61.3 years and 35.2% were female. The prevalence of stenosis was distributed as follows: 26.4% mild, 44.0% moderate, and 29.7% severe. Statistically significant correlations were observed between hypertension, smoking, hyperlipidemia, and the degree of stenosis (p < 0.05), but not with diabetes. The prevalence of left vertebral artery (VA) dominance was found to be 41.1%. Additionally, there was no gender connection observed in the distribution of steno-occlusion (p = 0.434). There is no notable correlation between the degree of stenosis and the dominant vertebral artery (p > 0.05). Conclusion: Angiographic findings reveal the complex relationship between the dominance of the VA, patterns of stenosis, and demographic factors. Individuals with a dominant VA had a greater likelihood of developing stenosis on the opposite non-dominant side. The high occurrence of severe stenosis highlights the need for tailored diagnostic and treatment approaches. Understanding vertebral stenosis as a multifaceted interaction of demographic, lifestyle, and anatomical variables is essential for enhancing treatment strategies.

Vertebral artery dissection as the underlying cause of ventral spinal epidural haematoma.

Spontaneous spine epidural haematoma is a rare occurrence, with an incidence of 0.1/100 000 inhabitants/year. The anterior location of the haematoma is very uncommon since the dural sac is firmly attached to the posterior longitudinal ligament. Vertebral artery dissection as its underlying cause is an exceptionally rare event, with only two documented cases.This article presents the case of young woman who arrived at the emergency room with a spinal ventral epidural haematoma extending from C2 to T10, caused by a non-traumatic dissecting aneurysm of the right vertebral artery at V2-V3 segment. Since the patient was tetraparetic, she underwent emergent laminectomy, and the vertebral artery dissection was subsequently treated endovascularly with stenting.Vertebral artery dissection with subsequent perivascular haemorrhage is a possible cause of spontaneous spine epidural haematoma, particularly when located ventrally in the cervical and/or high thoracic column. Hence the importance of a thorough investigation of the vertebral artery integrity.

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.

[Analysis of the clinical characteristics of V4 segment steal blood in the vertebral artery].

Objective: To explore the clinical characteristics of unilateral vertebral artery V4 segment occlusive lesions (severe stenosis or occlusion), where the contralateral vertebral artery can be compensated through blood flow and reverse supply to the posterior inferior cerebellarartery (PICA). Methods: This study is a retrospective case series of 66 patients with V4 segment occlusive lesions of unilateral vertebral artery diagnosed and treated from June 2020 to October 2022. Patient data were retrospectively collected, and their hemodynamic characteristics and imaging data were analyzed. Results: Of the 66 cases, 11 patients (16.7%) with V4 segment occlusive disease showed the blood flow of the vertebral artery on the opposite side of the lesion on the digital subtraction angiography (DSA), which can be reverse stolen to the posterior inferior cerebellar artery of the diseased side through the confluence point of the vertebrobasilar artery through the distal end of the ipsilateral vertebral artery V4. Owing to the lack of literature on this pathway and based on the characteristics of previous definitions of subclavian artery steal and carotid artery steal, we referred to this pathway as the vertebral artery V4 segment steal. In 6 patients (9.1%), transcranial Doppler ultrasound (TCD) and transcranial color Doppler ultrasound (TCCD) showed that the blood flow signal was not detected at the proximal end of the V4 segment of the affected side, rather the blood flow direction was reversed at the distal end of the V4 segment, resulting in compensatory acceleration of the blood flow velocity of the V4 segment of the contralateral vertebral artery. Conclusion: "V4 segment steal of vertebral artery" is a very rare route of vertebral artery steal. When V4 segment of the vertebral artery is occluded, clinicians should pay attention to observe the blood supply of PICA and whether there is such a steal route, to better evaluate the blood flow compensation and prognosis of patients.

[A case of suspected vertebral artery stump syndrome assessed by CT angiography].

A 55-year-old man developed ischemic stroke in the bilateral cerebellar hemispheres and bilateral occipital lobes. He was admitted to our hospital 17 months later with recurrent ischemic stroke in the posterior circulation. The left vertebral artery (VA) was occluded on brain magnetic resonance angiography but was visualized with a delay on continuous three-phase CT angiography (CTA). Conventional angiography confirmed a to-and-fro blood flow pattern at the distal end of the left VA, therefore the patient was diagnosed with VA stump syndrome (VASS). VASS is a recurrent posterior circulation ischemic stroke caused by thrombi in an occluded unilateral VA. VASS should be suspected in patients with unilateral VA occlusion and repeated posterior-circulation ischemic stroke. The diagnostic criteria for VASS include confirmation of VA occlusion and the presence of an antegrade flow component at the distal end. In this case, the presence of collateral circulation in the VA was suspected based on CTA findings, leading to the diagnosis of VASS. It was thus suggested that devising the imaging method of CTA may help diagnose VASS.

Bilateral vertebral artery injury leads to brain death following traumatic brain injury: a case report.

BACKGROUND: Vertebral artery injury is a rare condition in trauma settings. In the advanced stages, it causes death. CASE: A 31-year-old Sundanese woman with cerebral edema, C2-C3 anterolisthesis, and Le Fort III fracture after a motorcycle accident was admitted to the emergency room. On the fifth day, she underwent arch bar maxillomandibular application and debridement in general anesthesia with a hyperextended neck position. Unfortunately, her rigid neck collar was removed in the high care unit before surgery. Her condition deteriorated 72 hours after surgery. Digital subtraction angiography revealed a grade 5 bilateral vertebral artery injury due to cervical spine displacement and a grade 4 left internal carotid artery injury with a carotid cavernous fistula (CCF). The patient was declared brain death as not improved cerebral perfusion after CCF coiling. CONCLUSIONS: Brain death due to cerebral hypoperfusion following cerebrovascular injury in this patient could be prevented by early endovascular intervention and cervical immobilisation.

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.

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.

Vertebral Artery Access Considerations in Coil Embolization of Small Superior Cerebellar Artery Aneurysm.

BACKGROUND: Coiling of small superior cerebellar artery aneurysms (sSCAAs) is challenging. We aimed to describe anatomic considerations in the vertebral and basilar artery (VA and BA) morphology for decision making in the coiling of sSCAAs. METHODS: Eleven patients with sSCAAs (<5 mm) treated at our institution between April 2015 and February 2022 were included to show our concept of deciding access routes in the coiling of sSCAAs. The access route was decided on the basis of VA characteristics, BA curvature, and aneurysm laterality. Adequate aneurysm occlusion on angiography (Raymond-Roy grading scale I and II), good outcome (modified Rankin Score 0-2) at the last follow-up, and adverse outcomes were evaluated. RESULTS: Simple coiling (n = 2), a balloon-assisted technique (n = 3), and stent-assisted technique (n = 6) were selected. At the last follow-up (median 13.0 months), adequate aneurysm occlusion and good outcome were obtained in all 9 patients (n = 10). Adverse outcomes were not observed. When VA dominance was equal, in the straight BA, the microcatheter insertion into the ipsilateral VA to the aneurysm was favorable to form a "fulcrum" on the contralateral side and obtain microcatheter stability. When an aneurysm was on the concave aspect of the curved BA, microcatheter insertion into the ipsilateral VA was favorable. As for the convex aspect's aneurysm location, the microcatheter insertion into the contralateral VA can be favored. Further, we described the VA origin classification as it relates to ease of access from a transradial approach. CONCLUSIONS: Vertebrobasilar morphology may be important in deciding access routes in the coiling of sSCAAs.

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.