Rare case of bilateral vertebral artery stenosis caused by C4-5 spondylotic changes manifesting with bilateral bow hunter's syndrome.

BACKGROUND: Rotational vertebral artery occlusion syndrome refers to vertebrobasilar insufficiency as a result of mechanical occlusion or stenosis of the vertebral artery by head rotation. In most cases, symptoms are produced on extension or rotation to one side. No case of bow hunter's syndrome with bilateral presentation at the C4 level has yet been reported. CASE DESCRIPTION: A 54-year-old man presented with symptomatic bilateral bow hunter's syndrome induced by head rotation. The patient complained of intermittent dizziness, episodes of double vision, nonpulsatile tinnitus, and headaches indicative of vertebral artery insufficiency with exacerbation of symptoms on rotation of his head to either side. Computed tomography angiography showed bilateral vertebral artery stenosis, and dynamic cerebral angiography revealed bilateral rotational vertebral artery occlusion, with compression of the ipsilateral vertebral artery on head rotation to either side. Bilateral surgical decompression at C4-5 with anterior cervical diskectomy and fusion with a plate was performed. CONCLUSIONS: Bony obstruction of the vertebral artery on head rotation tends to occur at levels C4 and below, affecting the ipsilateral side. In this rare case, symptomatic bilateral vertebral artery stenosis occurred as a result of bony compression and was symptomatic on head rotation both to the right and to the left. This stenosis was improved with anterior decompression bilaterally, and no further events occurred postoperatively.

Timing and mechanism of ischemic stroke due to extracranial blunt traumatic cerebrovascular injury.

OBJECT: Extracranial cerebrovascular injury is believed to be an important cause of neurological injury in patients who have suffered blunt trauma. The authors sought to determine the timing and mechanisms of ischemic stroke in patients who suffered traumatic cerebrovascular injury (TCVI). METHODS: This is a prospective study of all patients with TCVI who were admitted to a Level I trauma center during a 28-month period. All patients who suffered blunt trauma and had risk factors for TCVI underwent screening CT angiography (CTA) of the head and neck on admission. All patients with either an ischemic stroke or CTA suggesting TCVI underwent confirmatory digital subtraction angiography (DSA). Patients with DSA-confirmed TCVI were treated with 325 mg aspirin daily; all patients were observed during their hospitalization for the occurrence of new ischemic stroke. In addition, a subset of patients with TCVI underwent transcranial Doppler ultrasonography monitoring for microembolic signals. RESULTS: A total of 112 patients had CTA findings suggestive of TCVI; 68 cases were confirmed by DSA. Overall, 7 patients had an ischemic stroke in the territory of the affected artery prior to or during admission. Four of the patients had their event prior to diagnosis with CTA and 2 occurred prior to DSA. In 1 patient the ischemic stroke was found to be due to an extracranial atherosclerotic carotid plaque, and this patient was excluded from further analysis. All patients with ischemic stroke had brain CT findings consistent with an embolic mechanism. Two (8.7%) of 23 monitored patients with TCVI had microembolic signals on transcranial Doppler ultrasonography. CONCLUSIONS: Most ischemic strokes due to TCVI are embolic in nature and occur prior to screening CTA and initiation of treatment with aspirin.

Infection risk in neurointervention and cerebral angiography.

BACKGROUND: The risk of infection with cerebral angiography and neurointerventional procedures has not been defined. Likewise, although the use of routine prophylactic antibiotics has been advocated by some neurointerventionalists, the utility of prophylactic antibiotics in this setting has not been determined. OBJECTIVE: To determine the rate of infection associated with neuroangiographic procedures in a clinical setting in which prophylactic antibiotics are not routinely given. METHODS: All cerebral angiograms and neurointerventional procedures done by a single neurointerventionalist over a recent 7-year period were retrospectively reviewed. Patients with infections directly attributable to the procedure were identified. A sample size calculation was done to determine the necessary size of a randomized, controlled trial aimed at determining whether prophylactic antibiotics can lower the rate of infection. RESULTS: Among a total of 2918 cerebral angiograms and neurointerventional procedures done without prophylactic antibiotics, there were 3 infections (0.1%) attributable to the procedure. All infections were localized femoral artery infections with no systemic complications. One infection occurred in a patient who was immunosuppressed because of treatment for cancer. Two of the patients required surgical debridement; all were treated with intravenous antibiotics with resolution of all infections. There were no central nervous system infections and no deaths associated with the infections. CONCLUSION: These data suggest that the overall risk of infection associated with most neuroangiographic procedures is very low. Prophylactic antibiotic use may be a reasonable option for selected patients but is probably unnecessary for standard use in the context of meticulous care during procedures.

Safety and cost effectiveness of step-down unit admission following elective neurointerventional procedures.

OBJECTIVE: Post-procedure monitoring in a neurointensive care unit (NICU) after neurointerventional procedures is conventional at most centers. However, NICU resources are scarce and costly. The purpose of this study was to determine whether an intermediate care step-down unit could be a safe and cost-effective alternative to the NICU for patients after uncomplicated neurointerventional procedures. METHODS: A retrospective review was undertaken of 127 consecutive patients over a 3-year period undergoing elective neurointerventional procedures including treatment of intracranial aneurysms, tumors, arteriovenous malformations and dural arteriovenous fistulas. Seventy-one patients were admitted to a step-down unit and 56 patients were admitted to the NICU. Endpoints were post-procedural complications, hospital costs and length of stay. Patients admitted to the step-down unit were compared with patients admitted to the NICU. RESULTS: Patients admitted to the step-down unit did not have more complications than patients admitted to the NICU. Two patients admitted to the step-down unit had neurological complications after the procedure which were immediately recognized by nursing staff and adequately managed. The mean (SD) total cost per patient was $19,299 ($6955) for patients admitted to the step-down unit and $22,716 ($8052) for patients admitted to the NICU, resulting in a statistically significant cost saving for patients admitted to the step-down unit of $3417 (p=0.012). The mean (SD) total cost less procedural costs per patient was $8442 ($4062) for patients in the step-down unit and $10,631 ($4727) for those admitted to the NICU, which was also statistically significant (p=0.005). Length of stay averaged 21.7 h for patients admitted to the step-down unit and 24.9 h for those admitted to the NICU (p=0.016). CONCLUSIONS: A step-down unit is a safe and cost-effective alternative to the NICU for patients undergoing elective neurointerventional procedures.

Rebleeding risk after treatment of ruptured intracranial aneurysms.

OBJECT: Postprocedural rebleeding is a significant source of morbidity following endovascular treatment of ruptured intracranial aneurysms. Previous large-scale reports include the Cerebral Aneurysm Rerupture After Treatment trial, the International Subarachnoid Aneurysm Trial, and the study on Early Rebleeding after Coiling of Ruptured Cerebral Aneurysms, which reported nonprocedural rebleeding rates within 30 days of treatment of 2.7%, 1.9%, and 1.4%, respectively. However, coiling of intracranial aneurysms is in a state of continual change due to advancing device design and evolving techniques. These studies included only patients initially treated prior to 2004. In the present study the authors assess the most recent short-term results with endovascular treatment of ruptured aneurysms. METHODS: A multicenter retrospective chart review was conducted of patients undergoing endovascular treatment for ruptured intracranial aneurysms between July 2004 and October 2009. The technique used, including the use of stent or balloon assistance, was evaluated. Demographic and clinical factors, such as sex, age, initial clinical presentation, aneurysm size, aneurysm location, and modified Raymond Classification following initial treatment, were also evaluated and compared between the groups in which rebleeding did and did not occur. RESULTS: A total of 469 patients underwent endovascular treatment for a ruptured aneurysm; nonprocedural rehemorrhage occurred within 30 days of the initial coiling in 4 cases (0.9%). Two patients (50%) died after rehemorrhage. Stent-assisted coiling was used during the original treatment in 1 (25%) of the 4 patients with a rerupture. However, no technical, clinical, or demographic factors were found to be statistically significant in association with rebleeding. CONCLUSIONS: Recent data suggest that the periprocedural rebleeding rate may be improving over time.