Vertebral artery dissection induced lateral medullary syndrome characterized with severe bradycardia: a case report and review of the literature.

BACKGROUND: Lateral medullary syndrome is the most common type of brainstem infarction. Lateral medullary syndrome results in damage to the corresponding cranial nerve nuclei and the nucleus tractus solitarius, with vertigo, ipsilateral ataxia, crossed sensory disturbances, Horner's sign, bulbar palsy, and other underlying symptoms or signs. However, cases with cardiac arrhythmia and other autonomic dysfunctions as the primary manifestations are less common. Clinically, sudden death occasionally occurs in patients with lateral medullary syndrome, which may be associated with severe cardiac arrhythmia. These patients may suffer in life-threatening arrhythmia and even cardiac arrest, and vital signs should be closely monitored to prevent sudden death. In younger patients, vertebral artery dissection is the most common cause. CASE DESCRIPTION: Here, we present a case of lateral medullary syndrome caused by vertebral artery dissection with severe bradycardia. The patient was a 49-year-old man who was admitted with "sudden onset of numbness in the left limbs and right side of the face for 1 hour". Electrocardiogram (ECG) monitoring showed a repeated heart rate decrease to as low as 23 beats/min, followed by a gradual increase in heart rate to 35-55 beats/min after 2-3 seconds. Head magnetic resonance imaging (MRI) examination revealed right dorsolateral cerebral infarction of the medulla oblongata. Digital subtraction angiography (DSA) revealed a right vertebral artery dissecting aneurysm. We performed an emergency placement of a temporary pacemaker, followed by conservative treatment with platelet aggregation inhibitors, vascular softening agents and improved collateral circulation. Elective spring coil embolization of the vertebral artery dissecting aneurysm and stent implantation were performed. At outpatient follow-up, the patient had a good prognosis. CONCLUSIONS: Clinical management of patients with lateral medullary syndrome should be prioritized, with close cardiac monitoring at the early stages of observation and pacemaker placement and tracheal intubation as required to prevent adverse events.

Factors Predictive of Enlargement of Dissecting Aneurysms in the Vertebral Artery.

OBJECTIVE: To elucidate the incidence rate of enlargement of vertebral artery dissecting aneurysms (VADAs) during the acute phase and factors associated with enlargement. METHODS: Of 115 patients with unilateral intracranial vertebral artery dissection who did not experience subarachnoid hemorrhage, 64 with the pearl sign of vertebral artery dissection (VADA without stenosis) participated in the study. We performed initial magnetic resonance imaging to diagnose VADA and subsequent magnetic resonance imaging to evaluate VADA enlargement. The presence of a hyperintense intramural signal was confirmed using T1-weighted three-dimensional turbo spin-echo imaging. Enlargement of VADAs between the initial and subsequent examinations was evaluated via magnetic resonance angiography and defined as the end point. We studied the rate of VADA enlargement using Kaplan-Meier curve analysis. After independent variables were determined, the Cox proportional hazards model was applied in multivariable analysis to identify the factors significantly associated with VADA enlargement. RESULTS: Of 64 patients (mean age, 55.7 ± 13.0 years; 44 men and 20 women), 15 exhibited VADA enlargement. Kaplan-Meier curve analysis indicated that 24.8% of VADA enlargements were detected 30 days after initial magnetic resonance imaging. The Cox proportional hazards model revealed that young age (hazard ratio 0.953, P = 0.043) and the presence of hyperintense intramural signal (hazard ratio 2.841, P = 0.033) were significantly associated with VADA enlargement. CONCLUSIONS: VADAs enlarged by approximately 25% until day 30 after the initial examination. Younger age and the presence of hyperintense intramural signal were significantly associated with VADA enlargement.

High-Resolution Magnetic Resonance Imaging (HR-MRI) Imaging Characteristics of Vertebral Artery Dissection with Negative MR Routine Scan and Hypoperfusion in Arterial Spin Labeling.

BACKGROUND Unruptured vertebral artery dissection (VAD) that causes ischemic infarction may require anticoagulant therapy or other treatments. However, anticoagulation therapy is not recommended for patients without ischemic infarction. To date, there has been no research on the imaging characteristics of patients with ischemic hypoperfusion that have a negative routine MRI scan. MATERIAL AND METHODS Patients with suspected VAD were recruited between June 2015 and June 2020 in order to perform high-resolution magnetic resonance imaging (HR-MRI). In total, 26 patients with negative MRI routine scans that underwent arterial spin labeling (ASL) examination were included in the study. The patients were divided into the hypoperfusion group and normal group based on whether hypoperfusion was found in ASL. The clinical features and HR-MRI features between these 2 groups were analyzed. RESULTS There were no statistical differences between the hypoperfusion group and normal group based on the patient's clinical characteristics (P>0.05). According to imaging characteristics between the 2 groups, the effective lumen index and the vertebrobasilar artery minimum angle were statistically significant (P.

Massive Brainstem and Cerebellum Infarction Due to Traumatic Extracranial Vertebral Artery Dissection in a Motor Traffic Accident: An Autopsy Case Report.

ABSTRACT: Traumatic unilateral vertebral artery (VA) injury can cause focal thrombosis and may block the basilar artery which can further lead to ischemic stroke and massive cerebral infarction and subarachnoid hemorrhage and even rapid death. Here, we present an autopsy case with a traumatic extracranial VA dissection in a motor traffic accident, and the identification of cause of death underwent 2 autopsies. A 62-year-old male pedestrian collided with the right rearview mirror of a car and fell down to the ground. He complained pains in the head and neck. Head computed tomography (CT) showed a right linear temporal bone fracture and a small left temporal subdural hematoma. Neck CT and magnetic resonance imaging (MRI) examination showed left transverse process fracture of the sixth cervical vertebra (C6) and left extracranial VA injury. After 6 days of hospitalization, the left temporal subdural hematoma had been nearly absorbed, and the man was discharged home. On day 15 after the traffic accident, the man suffered sudden unconsciousness accompanied by frequent vomiting at home. The man was taken to hospital, and there were no obvious abnormal findings by head CT examination. However, the man soon fell into a coma state and died 2 days later. The first autopsy was performed 7 days after death and confirmed a left transverse process fracture of C6 and that the deceased died of cerebral infarction and secondary subarachnoid hemorrhage caused by blunt force in the motor traffic accident. In the civil lawsuit, the traffic accident wrecker put forward the objection whether the deceased had fatal diseases. The second autopsy (84 days after the death) findings verified the left extracranial VA injury. Histopathological examination further showed intimal dissection and thrombus formation of the left extracranial VA and secondary basal arterial thromboembolism. Massive infarction of the brainstem and cerebellum was disclosed. Therefore, the deceased died of delayed massive brainstem and cerebellum infarction because of left extracranial VA dissection in the motor traffic accident.

Predisposing factors and radiological features in patients with internal carotid artery dissection or vertebral artery dissection.

BACKGROUND: Cervicocerebral artery dissection is an important cause of ischemic stroke in young and middle-aged individuals. However, very few studies have compared the differential features between internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD), including both cervical and intracranial artery dissections. We conducted a study to investigate the predisposing factors and radiological features in patients with ICAD or VAD. METHODS: All cases diagnosed with cervicocerebral artery dissection, ICAD, or VAD were identified through a medical records database, between January 2010 and January 2020. Baseline characteristics, predisposing factors, and radiological features of ICAD versus VAD were compared. RESULTS: A total of 140 patients with cervicocerebral artery dissection were included in the study, including 84 patients in the ICAD group and 56 in the VAD group. The mean age of patients in the ICAD and VAD groups was 43.37 ± 14.01 and 41.00 ± 12.98 years old, respectively. Patients with ICAD were more likely to be men compared with VAD (85.71% vs. 67.86%, p = 0.012). The frequency of hypertension, diabetes, smoking, drinking, and cervical trauma did not differ between ICAD and VAD. Dissections of ICAD were more frequently at the extracranial portions of the artery compared with those of VAD (70.24% vs. 44.64%, p = 0.003). In contrast, dissections of VAD were more common in the intracranial artery (55.36% vs. 29.76%, p = 0.003). Radiologically, double lumen (36.90% vs. 19.64%, p = 0.029) and intimal flap (11.90% vs. 1.79%, p = 0.029) were more frequently observed in ICAD than in VAD, and dissecting aneurysms were less frequent (13.10% vs. 26.79%, p = 0.041). CONCLUSIONS: The distributions of cervical and intracranial artery dissections were different between ICAD and VAD. The frequencies of radiological features detected in patients with ICAD and VAD also differed.

Traumatic cervical vertebral artery dissection: A case with cerebral infarct due to newly formed thrombus in the cerebral arteries.

We report a 50-year-old man who developed fatal brainstem infarction five days after traumatic cervical vertebral artery dissection (CVAD). Autopsy revealed multiple fresh infarcts in the territory of the vertebrobasilar system. No thrombus was found in the infarct lesions. The cervical vertebral artery (CVA) showed severe atherosclerotic stenosis extending to the proximal half of the left side, similar stenosis at the origin on the right side, fresh thrombotic occlusion extending to the proximal half of the right side, and multiple dissections in the distal foraminal segments on both sides. In the distal half of the basilar artery (BA) and the origin of the right posterior cerebral artery (PCA), the lumen was extensively filled with fresh thrombus. Although an intricate mixture of white and red thrombi filled the lumen at the origin of the right PCA, the white thrombus gradually appeared at the periphery whereas the red thrombus occupied the central and more proximal part of the BA. We confirm that cerebral infarction associated with CVAD is due not only to emboli originating from the dislodged thrombus at sites of arterial dissection, as reported previously, but also to newly formed thrombus in the cerebral arteries caused by impaired blood flow, as was seen in the present case.

Clinical Features of Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage.

OBJECTIVE: Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by acute onset after central nervous system injury. Here, we investigated the clinical features of NPE in patients with subarachnoid hemorrhage (SAH). METHODS: We retrospectively analyzed a total of 350 patients with SAH who were treated at our hospital from April 2014 to September 2017. Patient demographics, aneurysm size and location, clinical characteristics, and patient outcomes were reviewed and compared between an NPE and a non-NPE group. RESULTS: Sixteen patients (4.6%) presented with NPE at admission. Ten of these (62.5%) recovered from NPE immediately, and ventilatory support was withdrawn within 2 days from onset. A univariate analysis showed that patients with NPE were younger (P = 0.04), had a higher rate of vertebral artery dissection (P < 0.01), more severe World Federation of Neurosurgical Societies (WFNS) grades (P = 0.01), and lower systolic blood pressure on admission (P = 0.01). A multivariate analysis revealed significant differences in the frequency of vertebral artery dissection (odds ratio 4.83, 95% confidence interval 1.50-15.56, P < 0.01) and in WFNS grades (odds ratio 3.73, 95% confidence interval 1.02-13.66, P = 0.04) between the groups. No significant group differences were found in other factors including heart rate, radiographic sign (Fisher grade), aneurysm size and location, blood sample tests on admission, and neurologic outcomes. CONCLUSIONS: Vertebral artery dissection and severe WFNS grade on admission were confirmed as significant risk factors for NPE. However, neurologic outcomes at discharge did not differ between groups, suggesting that poor outcomes due to NPE could be reduced by appropriate diagnosis and treatment.

Association between morphologic subtypes of vertebral artery dissection and vertebral artery hypoplastic appearance.

OBJECTIVES: The purpose of this study was to evaluate the associations between vertebral artery hypoplasia (VAH) and the morphologic types of spontaneous vertebral artery dissection (sVAD) and to assess the chronological changes of VAH after sVAD. METHODS AND MATERIALS: In this retrospective study, we included 208 patients with 216 sVADs which were diagnosed between January 2003 and June 2017 at two tertiary hospitals. Morphologic types of sVAD were classified into aneurysmal dilatation without stenosis, pearl-and-string appearance, and steno-occlusion without aneurysmal dilatation. Baseline clinical characteristics and sVAD types were compared according to the presence of VAH on initial imaging. For 143 sVAD patients with follow-up imaging available, chronological changes of VAH and their associations with sVAD types were also evaluated. RESULT: VAH was detected in 29 (13.9%) subjects: 18 (8.7%) with ipsilateral VAH and 11 (5.3%) with contralateral VAH to the sVAD site. Primary lesion shape was statistically associated with the presence of VAH (P = 0.001); steno-occlusion without dilatation was more frequently observed in the ipsilateral VAH group (44.4%) than the no-VAH group (20.9%) or contralateral VAH group (0%). Of a total 143 sVAD patients with follow-up imaging available, VAH-like diffuse VA narrowing was newly observed in seven patients and four patients who were initially classified into the VAH group showed their VAH-like appearances resolved. CONCLUSIONS: The presence of VAH may be associated with the morphologic subtype of sVAD and the VA diameter can dynamically change, making it possible for the VAH-like appearance to be induced after a sVAD event.

Conservative Management of Unruptured Spontaneous Intracranial Vertebral Artery Dissection.

OBJECTIVE: The present study investigated the clinical and morphological characteristics of the vertebrobasilar artery associated with vascular healing in patients with unruptured spontaneous intracranial vertebral artery (VA) dissection (VAD). METHODS: We retrospectively reviewed the data from 69 consecutive patients with a diagnosis of unruptured VAD who were treated conservatively for ≥21 days from November 2003 to February 2018 at our institute. Univariate and multivariate analyses were performed to evaluate the clinical characteristics and morphological findings of VAD. RESULTS: Of the 69 patients, vascular normalization of VAD was observed in 26, including a significantly greater proportion of women and nonsmokers (P = 0.04 and P = 0.034, respectively). Patients with normalization of VAD had a significantly lower proportion of posteroinferior cerebellar artery involvement and a smaller vertebral-union-basilar angle of the nondissecting VA, smaller vertebral-union-vertebral angle, distal dissection from the VA union, and less basilar artery bending. Luminal irregularity/steno-occlusion of the VAD on the initial images exhibited vascular resolution/normalization in 25 patients (67.6%) on subsequent images. The morphology of VAD in the dominant or codominant VAs included fusiform/aneurysmal dilatation in 25 patients (78.1%). The morphology in the nondominant VA included luminal irregularity/steno-occlusion in 23 patients (62.2%). CONCLUSIONS: Spontaneous vascular normalization of unruptured spontaneous intracranial VAD might be associated with female sex, nonsmoking, no posteroinferior cerebellar artery involvement, a smaller vertebral-union-basilar angle and vertebral-union-vertebral angle, distal dissection from the VA union, less basilar artery bending, and luminal irregularity/steno-occlusion.

Early detection of vertebral artery dissection.

A 36-year-old female patient presented to hospital with a 1-week history of occipital headache. It was sudden onset following a fall into a swimming pool. Examination was unremarkable. CT angiogram brain scan showed right vertebral artery dissection with a 1 cm dissection flap and a 3 mm left middle cerebral artery aneurysm. She was discharged on aspirin, with outpatient neurology clinic follow-up.

Endovascular strategies for management of intradural vertebral artery dissecting aneurysms.

OBJECTIVE: Endovascular treatment of vertebral intradural dissecting aneurysms is complex and requires different strategies for each case. The current study aims to classify these aneurysms for an easy selection of optimal strategies for endovascular therapy. MATERIALS AND METHODS: This study is a retrospective evaluation of 10 patients harbouring a vertebral intradural dissecting aneurysm (including 6 female and 4 male patients). The clinical, procedural, and angiographic data were evaluated. RESULTS: Nine patients presented with acute subarachnoid hemorrhage and 1 with acute-onset headache. The aneurysms were classified into two types, depending on the developmental state of the contralateral vertebral artery: Dominant (A) and hypoplastic (B). Type A (n = 7) group was further divided into three subtypes on the basis of location of the aneurysm in relation to the posterior inferior cerebellar artery (PICA): aneurysm proximal to the PICA, Type I (n = 3); involving the PICA, Type II (n = 2); and, distal to the PICA, Type III (n = 2). Internal trapping was done for 4 patients in this group, 2 patients with aneurysm involving the PICA underwent proximal occlusion and 1 patient underwent stent-assisted coiling since he refused to undergo vertebral artery sacrifice. B Type patients (n = 3) were treated with reconstructive endovascular management. No symptomatic complication was seen in the patients with trapping. Antiplatelet medication-related complication was seen in 2 patients who underwent stent-assisted coiling. Clinical outcome at the time of discharge was good [modified Rankin score (mRS) 0-2] in 8 and poor (mRs >2) in 2 patients. At follow-up visit, one patient had developed severe cognitive impairment but was independent in activities of daily living. CONCLUSION: The classification of vertebral artery aneurysms based on their location and on the status of the contralateral vertebral artery appears to be an effective method for the selection of safe and appropriate endovascular therapy.

Utility of T1- and T2-Weighted High-Resolution Vessel Wall Imaging for the Diagnosis and Follow Up of Isolated Posterior Inferior Cerebellar Artery Dissection with Ischemic Stroke: Report of 4 Cases and Review of the Literature.

BACKGROUND: An accurate diagnosis of isolated posterior inferior cerebellar artery dissection (iPICA-D) is difficult due to the limitation of spatial resolution on conventional magnetic resonance imaging (MRI) techniques to detect subtle vessel wall abnormalities. The recent development of MRI techniques, including high-resolution vessel wall imaging (HRVWI), has resulted in the improved diagnostic accuracy and efficiency of iPICA-D. In fact, T1-weighted HRVWI, which can reveal intramural hematomas in the posterior inferior cerebellar artery (PICA), is useful for the diagnosis of iPICA-D. However, the utility of T2-weighted HRVWI has not been previously reported. The aim of this study was to investigate the diagnostic utility of T1- and T2-weighted HRVWI for the diagnosis of iPICA-D. METHODS: We retrospectively evaluated MRI findings including intramural hematomas, dilations, and chronological changes in 4 patients with iPICA-D admitted to our hospital and related facility from January 2015 to August 2016. In addition to T1-weighted HRVWI, T2-weighted HRVWI was performed on isovoxel three-dimensional (3D) fast spin-echo or 3D sampling perfection with application-optimized contrast using different flip-angle evolution. We also reviewed cases of nonhemorrhagic iPICA-D with ischemic onset in which the MRI findings were described. RESULTS: In all 4 patients, in addition to the intramural hematomas on T1-weighted HRVWI, T2-weighted HRVWI clearly showed the fusiform dilation of the external diameter of the PICA. T2-weighted HRVWI was more useful than other techniques, including T1-weighted HRVWI, for the evaluation of arterial shape changes. CONCLUSIONS: Like T1-weighted HRVWI, T2-weighted HRVWI is useful for the diagnosis and assessment of chronological changes in vessel wall abnormalities during the follow-up period.

Clinical Presentation, Magnetic Resonance Angiography, Ultrasound Findings, and Stroke Patterns in Patients with Vertebral Artery Dissection.

BACKGROUND/AIMS: Vertebral artery dissection (VAD) is an important cause of ischemic stroke. In this observational study, clinical data, magnetic resonance (MR) and ultrasound (US) imaging findings and ischemic patterns were analyzed. METHODS: Forty-seven patients with a diagnosis of VAD underwent clinical examination, US, MR of the brain and neck and MR angiography (MRA) of the cervical arteries. Vascular abnormalities and ischemic brain lesions were noted. Data were evaluated separately and compared for spontaneous and traumatic VAD subgroups. RESULTS: The most common overall clinical symptom was vertigo followed by neck pain. In the traumatic subgroup, vertigo was relatively rare (p = 0.022). Most common MRA findings were vessel irregularity and vessel occlusions. Ischemic lesions occurred significantly more frequently after spontaneous than after traumatic VAD (p = 0.009). Unilateral VAD was significantly more common in non-dominant vertebral arteries (p < 0.001). Mortality after trauma was not only due to VAD complications but also due to other trauma-related injuries. CONCLUSION: The variability of MR and US imaging findings in patients with VAD is illustrated. The algorithm of management should be based on a multimodality approach involving patient history and clinical neurological examination. Several types of vessel abnormalities and ischemic lesion in diverse locations may point to arterial dissection, and the differential diagnosis of VAD must be kept in mind.

Aberrant Origin of Vertebral Artery and its Clinical Implications.

Aberrant origin of vertebral artery is rare. The anatomical features and clinical significance of this lesion remain to be clarified. A comprehensive collection of the pertinent literature resulted in a cohort of 1286 cases involving 955 patients and 331 cadavers. There were more left than right and more unilateral than bilateral aberrant vertebral arteries. Patients with aberrant origin of vertebral artery were often asymptomatic and in only 5.5% of the patients their symptoms were probably related to the aberrant origin of vertebral artery. The acquired cardiovascular lesions were present in 9.5% of the patients, 20.9% of which were vertebral artery-associated lesions. Eight (0.8%) patients had a vertebral artery dissection. Logistic regression analysis showed significant regressions between bovine trunk and left vertebral artery (P=0.000), between the dual origins of vertebral artery and cerebral infarct/thrombus (P=0.041), between associated alternative congenital vascular variants and cervical/aortic dissection/atherosclerosis (P=0.008). Multiple logistic regression demonstrated that side of the aberrant origin of vertebral artery (left vertebral artery) (P=0.014), arch branch pattern (direct arch origin) (P=0.019), presence of the common trunk (P=0.019), associated acquired vascular disorder (P=0.034) and the patients who warranted management (P=0.000) were significant risk predictors for neurological sequelae. The patients with neurological symptoms and those for neck and chest operations/ interventions should be carefully screened for the possibility of an aberrant origin of vertebral artery. The results from the cadaver metrology study are very helpful in the design of the aortic stent. The arch branch pattern has to be taken into consideration before any maneuver in the local region so as to avoid unexpected events in relation to aberrant vertebral artery.

Cerebrum-cervical arterial dissection in adults during sports and recreation / Dissecção arterial cérebro-cervical em adultos durante prática de esportes e recreação

Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities. Methods Retrospective data on patients with arterial dissection related to sports and recreation. Results Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature. Conclusion Arterial dissection may be a complication from practicing sports.

A dissecção das artérias cervicais é uma emergência médica. Embora de forma relativamente rara, certas atividades descritas como esportes e recreação podem ser a causa de dissecção arterial independentemente de trauma de crânio ou cervical. O propósito do presente estudo é apresentar uma série de casos de dissecção de artérias cérebro-cervicais em indivíduos durante ou logo após a prática destas atividades desportivas. Métodos Dados retrospectivos de pacientes com dissecção arterial relacionada à prática de esportes e recreação. Resultados Quarenta e um casos foram identificados. A artéria mais frequentemente afetada foi a vertebral. Uma grande variedade de atividades teve relação temporal com a dissecção arterial, sendo a corrida a mais frequente delas. Esta é a maior série de casos da literatura. Conclusão Dissecção arterial pode ser uma complicação da prática de esportes.

Radical treatment for bilateral vertebral artery dissecting aneurysms by reconstruction of the vertebral artery.

OBJECTIVE Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery. METHODS Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms. RESULTS The post-coil embolization patients underwent V3-posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V3-V4 or V4-V4 bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable. CONCLUSIONS Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V3-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.

Aberrant Origin of Vertebral Artery and its Clinical Implications

Abstract Aberrant origin of vertebral artery is rare. The anatomical features and clinical significance of this lesion remain to be clarified. A comprehensive collection of the pertinent literature resulted in a cohort of 1286 cases involving 955 patients and 331 cadavers. There were more left than right and more unilateral than bilateral aberrant vertebral arteries. Patients with aberrant origin of vertebral artery were often asymptomatic and in only 5.5% of the patients their symptoms were probably related to the aberrant origin of vertebral artery. The acquired cardiovascular lesions were present in 9.5% of the patients, 20.9% of which were vertebral artery-associated lesions. Eight (0.8%) patients had a vertebral artery dissection. Logistic regression analysis showed significant regressions between bovine trunk and left vertebral artery (P=0.000), between the dual origins of vertebral artery and cerebral infarct/thrombus (P=0.041), between associated alternative congenital vascular variants and cervical/aortic dissection/atherosclerosis (P=0.008). Multiple logistic regression demonstrated that side of the aberrant origin of vertebral artery (left vertebral artery) (P=0.014), arch branch pattern (direct arch origin) (P=0.019), presence of the common trunk (P=0.019), associated acquired vascular disorder (P=0.034) and the patients who warranted management (P=0.000) were significant risk predictors for neurological sequelea. The patients with neurological symptoms and those for neck and chest operations/ interventions should be carefully screened for the possibility of an aberrant origin of vertebral artery. The results from the cadaver metrology study are very helpful in the design of the aortic stent. The arch branch pattern has to be taken into consideration before any maneuver in the local region so as to avoid unexpected events in relation to aberrant vertebral artery.

Basilar dolichoectasia and the spontaneous intradural vertebral artery dissection.

OBJECT: Basilar dolichoectasia (BD) is an atherosclerotic, a distinct arteriopathy or a chronic-phase dissection characterized by elongation and dilation of the basilar artery. Spontaneous intradural vertebral artery dissection (siVAD) is an important cause of stroke in young and middle-aged people. It is hypothesized that the BD and the siVAD might partially share aetiologies and this study aimed to examine the relationship. METHODS: This study compared clinical and radiological characteristics in 93 patients with siVAD with 93 controls. Ectasia was defined as basilar artery diameter >4.5 mm and dolichosis, as either basilar artery bifurcation above the suprasellar cistern or lateral to the margin of the clivus or dorsum sellae. The BD was defined if both ectasia and dolichosis were simultaneously observed. Multivariate logistic regression analysis was performed using variables that were marginally or significantly associated with siVAD on univariate analysis (p < 0.20). RESULTS: Multivariate analysis showed siVAD patients have higher proportions of hypertension (OR = 2.4; 95% CI = 1.3-4.6; p = 0.007) and BD (OR = 3.7; 95% CI = 1.1-12; p = 0.036). CONCLUSIONS: The present study suggested that BD was related to the siVAD. A randomized study from multi-institutions with an adequate sample size is needed to make a strong argument about the association between BD and siVAD.