Cervical Vertebral Artery Research Articles

Anesthetic Management and Considerations During Surgical Dissection of a Schwannoma Causing Severe Cervical Spinal Canal Stenosis and Vertebral Artery Compression

Anesthetic Management and Considerations During Surgical Dissection of a Schwannoma Causing Severe Cervical Spinal Canal Stenosis and Vertebral Artery Compression

Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review.

Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.

Impact of Cervical Vertebral Artery Tortuosity on the Outcome After Mechanical Thrombectomy for Basilar Artery Occlusion

Background Vascular tortuosity affects the outcomes of mechanical thrombectomy (MT). We classified vertebral artery (VA) tortuosity into 3 types and investigated the effect of VA tortuosity on the outcomes in patients with basilar artery occlusion. Methods We retrospectively included patients who underwent MT for basilar artery occlusion between January 2012 and May 2022. Clinical and procedure‐related factors were obtained. VA tortuosity was classified into 3 types: type I: nontortuous VA; type II: S‐shaped vessel or a VA with a single acute angulation (<90°); and type III: coiled vessel, kinked vessel, or a VA with acute angulation in >1 location. The 3‐month modified Rankin scale, procedural outcomes, and post‐MT intracranial hemorrhage were assessed. Results A total of 106 patients with basilar artery occlusion were included. Age, baseline stroke severity, and 3‐month modified Rankin scale score were significantly different according to VA tortuosity ( P = 0.003, P = 0.002, and P <0.001, respectively). A multivariable analysis demonstrated that the VA tortuosity was a predictor for the achievement of modified Rankin scale score of 0 to 3 (type I: reference; type II: odds ratio [OR] = 0.26, 95% CI = 0.07–0.95, P = 0.041; type III: OR = 0.12, 95% CI = 0.02–0.82, P = 0.031). Moreover, type III was associated with less successful recanalization (type I: reference; type III: OR = 0.12, 95% CI = 0.02–0.84, P = 0.032) and had a potential trend for post‐MT intracranial hemorrhage (type I: reference; type III: OR = 3.09, 95% CI = 0.83–11.56, P = 0.094). Conclusion We classified VA tortuosity into 3 types and showed the association between VA tortuosity and stroke outcomes after MT for basilar artery occlusion. Particularly, the mechanisms of poor outcomes in highly tortuous VA might be associated with baseline stroke severity, recanalization failure, and post‐MT intracranial hemorrhage.

Abstract 124: Vertebral Artery Web as a Rare Cause of Ischemic Stroke in a young male

Introduction Vertebral artery web has been rarely identified compared to the frequently reported, carotid artery web as etiology of ischemic stroke. Here we present a young patient with symptomatic vertebral artery web. Methods Case Report Results 35‐year‐old male presented with persistent, intermittent, bilateral visual scintillations lasting 30‐60 seconds for one month. Neurological examination positive for bi nasal superior quadrantanopia. Computed tomography (CT) of head showed patchy hypo density in right posterior circulation artery (PCA) territory. Magnetic resonance imaging (MRI) showed restriction diffusion over bilateral PCA territories right greater than left (image A). MR Angiogram head and neck showed abnormal contour within right vertebral artery in V2 segment compatible with dissection (image B). Patient’s hypercoaguable, inflammatory and rheumatological markers were unremarkable. The patient was started on aspirin 81 mg daily and Plavix 75 mg daily for three weeks followed by aspirin monotherapy. Repeat CT angiogram 11 months later still showed right V1/V2 junction irregularity (image C). DSA performed one month later revealed right cervical vertebral artery web with mild stagnation of blood flow (image D). Patient had no recurrence of symptoms and was continued on aspirin. Conclusion Ischemic stroke is rare in young adults. According to recent studies, prevalence of stroke in young adults’ ranges from 10‐15% of entire population stroke burden. Our case describes a young patient with posterior circulation stroke caused by a vertebral artery web which was confirmed with DSA. Vertebral artery web has limited scientific documentation throughout the literature. A literature review performed by B.J.A. Pereira et al. demonstrated that only 7.3% of vessel webs were found in the vertebral artery, compared to 91.66% in the carotid artery (3). Because of this, a review of medical literature showed limited case reports on treatment and surgical options for vertebral webs causing posterior circulation stroke. Lenck et al. first reported 3 patients with vertebral webs diagnosed by DSA and having MRI show ischemic strokes in the vascular territory were treated with endovascular stenting and had no recurrence of an ischemic event (4). A literature review reported by Pereira demonstrated that out of 23 vessel webs, 13 were treated with supportive care (including antiplatelets or anticoagulation), eight were treated with angioplasty and stenting (which included the vertebral artery web case), and two were treated with surgery (3). In other literature, Lizhang et al (2019) diagnosed an incidental vertebral artery web on DSA for anterior circulation TIA and was treated successfully with DAPT therapy and atorvastatin 20 mg (5).

Ruptured vertebrobasilar junction aneurysm supplied by reversed flow from the anterior spinal artery: Illustrative case report.

In patients with vertebral artery (VA) occlusion, spontaneous flow reversal may occur in the anterior spinal artery (ASA) as a source of compensatory supply to the posterior circulation. Turbulent flow and increased flux through these small arteries may predispose to luminal damage and intracranial aneurysm formation. We report a novel case of a ruptured ASA-VA junction aneurysm in a patient with chronic bilateral VA occlusion, successfully treated with endovascular embolization. A 62-year-old female with uncontrolled hypertension presented with acute-onset headache, emesis, neck stiffness, and decreased level of consciousness. Head computed tomography demonstrated diffuse cisternal subarachnoid hemorrhage with intraventricular extension and ventriculomegaly. Computed tomography angiography showed left VA atresia and chronic right VA occlusion just distal to the posterior inferior cerebellar artery origin, as well as a complex, bilobed aneurysm at the ASA-VA junction. Angiography demonstrated flow reversal from the ASA into the distal stump of the occluded right VA, which in turn filled the aneurysm. Of note, the patient's posterior circulation was predominantly supplied by the dilated ASA, and associated collaterals from ASA and right VA stump. The aneurysm was accessed and embolized using superselective microcatheterization over a soft microguidewire through the right cervical VA perforators supplying retrograde flow into and through the ASA. ASA-VA aneurysms are exceedingly rare, and generally associated with atypical flow dynamics. Dynamic treatment strategies may be needed, especially in the setting of subarachnoid hemorrhage.

Trauma mechanisms and patterns of blunt cervical vascular injury: A descriptive study using a nationwide trauma registry

ObjectiveBlunt cervical vascular injury (BCVI) is a non-penetrating trauma to the carotid and/or vertebral vessels following a direct injury to the neck or by the shearing of the cervical vessels. Despite its potentially life-threatening nature, important clinical features of BCVI such as typical patterns of co-occurring injuries for each trauma mechanism are not well known. To address this knowledge gap, we described the characteristics of patients with BCVI to identify the pattern of co-occurring injuries by common trauma mechanisms. MethodsThis is a descriptive study using a Japanese nationwide trauma registry from 2004 through 2019. We included patients aged ≥13 years presenting to the emergency department (ED) with BCVI, defined as a blunt trauma to any of the following vessels: common/internal carotid artery, external carotid artery, vertebral artery, external jugular vein, and internal jugular vein. We delineated characteristics of each BCVI classified according to three damaged vessels (common/internal carotid artery, vertebral artery, and others). In addition, we applied network analysis to unravel patterns of co-occurring injuries among patients with BCVI by four common trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height). ResultsAmong 311,692 patients who visited the ED for blunt trauma, 454 (0.1%) patients had BCVI. Patients with common/internal carotid artery injuries presented to the ED with severe symptoms (e.g., the median Glasgow Coma Scale was 7) and had high in-hospital mortality (45%), while patients with vertebral artery injuries presented with relatively stable vital signs. Network analysis showed that head-vertebral-cervical spine injuries were common across four trauma mechanisms (car accident, motorcycle/bicycle accident, simple fall, and fall from a height), with co-occurring injuries of the cervical spine and vertebral artery being the most common injuries due to falls. In addition, common/internal carotid artery injuries were associated with thoracic and abdominal injuries in patients with car accidents. ConclusionsBased on analyses of a nationwide trauma registry, we found that patients with BCVI had distinct patterns of co-occurring injuries by four trauma mechanisms. Our observations provide an important basis for the initial assessment of blunt trauma and could support the management of BCVI.

Flow diversion jet: A dangerous mechanism in the flow diversion treatment of giant intracranial aneurysms.

Cerebral hyperperfusion syndrome (CHS) occurs after the restoration of blood flow to a previously low-flow, low-pressure region of the cerebral vasculature, which subsequently responds with chronic compensatory vasodilation, leading to a dysregulated state. Sudden restoration of normal blood flow can overwhelm the vasculature leading to intracranial hemorrhage (ICH). Separately, the Windkessel phenomenon describes the capacity for elastic vessels to expand with systolic pressure and decompress with diastole, thereby suppressing distal pulse pressure. We encountered a case involving giant basilar aneurysms in which we believe the Windkessel phenomenon precipitated a catastrophic manifestation of CHS at treatment. We present a 60-year-old female found to have marked dolichoectasia of the right cervical internal carotid, vertebral, and basilar arteries concurrent with two large vertebrobasilar dissecting-type fusiform aneurysms. Managed conservatively for ten years before developing gait ataxia, new imaging revealed dramatic interval growth of the larger aneurysm. Flow diversion with partial coiling of the aneurysms was pursued. The patient suffered intra-procedural catastrophic thalamic and midbrain hemorrhage with intraventricular extension. A meticulous review of the case data was undertaken. Our findings suggest that giant aneurysms can act as a Windkessel reservoir, depressing the distal pulse pressure. Flow diversion bypasses the reservoir, increasing the distal pulse pressure beyond the autoregulatory capacity, resulting in ICH analogous to CHS. CHS and Windkessel phenomenon can contribute to catastrophic sequelae in the treatment of giant intracranial aneurysms with flow diversion. Awareness of this mechanism can protect future patients from harm.

Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room

BackgroundThis study aimed to determine the feasibility of ultrasonography in the assessment of cervical vertebral artery (VA) injury as an alternative to computed tomography angiography (CTA) in the emergency room.MethodsWe analyzed 50 VAs from 25 consecutive patients with cervical spine injury that had been admitted to our emergency room. Ultrasonography and CTA were performed to assess the VA in patients with cervical spine injury. We examined the sensitivity and specificity of ultrasonography compared with CTA.ResultsAmong these VAs, six were occluded on CTA. The agreement between ultrasonography and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of ultrasonography were 100%, 97.7%, 85.7%, and 100%, respectively. In one case with hypoplastic VA, the detection of flow in the VA by ultrasonography differed from detection by CTA. Meanwhile, there were two cases in which VAs entered at C5 transverse foramen rather than at C6 level. However, ultrasonography could detect the blood flow in these VAs.ConclusionsUltrasonography had a sensitivity of 100% compared with CTA in assessment of the VA. Ultrasonography can be used as an initial screening test for VA injury in the emergency room.

Extracranial Internal Carotid and Vertebral Dissecting Pseudoaneurysms: Clinical Features and Long‐Term Outcomes

Background The formation of dissecting pseudoaneurysms (dPSAs) is a common sequela of cervical artery dissection, which has been suggested to increase thrombotic risk in previous studies. This study reported clinical features and long‐term outcomes of cervical internal carotid (cICA) and vertebral artery (cVA) dPSAs. Methods We performed a retrospective chart review over a 10‐year period (January 2012–December 2021). Baseline demographics and clinical characteristics, medical and endovascular treatments, and long‐term outcomes were reported for cICA and cVA dPSA groups separately. Nonparametric tests were used to compare group differences. Results In our cohort, 120 (12%) of 999 cervical artery dissection patients had dPSA, with 85% occurring in the cICA and 15% in the cVA. Most dPSAs occurred spontaneously or in association with minor trauma. Compared with cICA dPSA, patients with cVA dPSA were younger (median age [range]=34.5 [24–70] versus 52 [30–77]; P <0.01), had a smaller dPSA size (median size [range]=4.5 mm [2–17] versus 8 mm [1.2–32]; P <0.01), and were more likely to reduce in size at follow‐up (median size change [range]=−2.8 mm [−17;0] versus 0 [−24;10.8]). Antithrombotic therapy was predominately aspirin monotherapy. No patients with cVA dPSA experienced recurrent strokes and only 3% of patients with cICA dPSA developed new/recurrent stroke in the territory of dPSA while on an antithrombotic regimen requiring endovascular intervention, and none of the dPSAs ruptured. A total of 98% of the patients had an excellent outcome (modified Rankin scale 0–2 at final follow‐up). Conclusion Most cICA and cVA dPSAs have a benign prognosis with medical therapy alone. Further prospective randomized clinical trials are needed to provide high quality evidence on the necessity of additional endovascular therapy at diagnosis in addition to medical therapy alone.

Imaging study on the safety of axial pedicle screw placement by the position of the screw trajectory tip on the anteroposterior and lateral radiographs

Objective: To propose a method to judge the safety of axial pedicle screw placement based on the position of the tip of the screw trajectory on the anteroposterior and lateral X-ray radiographs. Methods: The cervical CT data of 40 patients admitted to the Second Affiliated Hospital of Wenzhou Medical University from December 2020 to December 2021 were selected, including 24 males and 16 females, with a mean age of (47.6±13.2) years. Based on the three-dimensional model reconstruction of Mimics software and its function of X-ray, the transmission of the axial pedicle screw and its anteroposterior and lateral films was simulated. The position of the tip of the simulated screw trajectory was divided into 5 regions (regions Ⅰ-Ⅴ) from the inside to the outside on the anteroposterior virtual radiographs, and the upper and lower regions (regions a, b) on the lateral virtual radiographs. By adjusting the direction of the screw, the tip of the screw was located in the corresponding 10 regions (80 screws in each area) on the virtual projections of the anteroposterior and lateral virtual radiographs respectively, and its accuracy was analyzed by CT to determine whether each screw penetrated the medial wall of the pedicle or vertebral artery foramen. The anteroposterior and lateral X-rays and postoperative CT data of 34 patients who underwent axial pedicle screw placement (67 axial pedicle screws were placed in total) from January 2014 to December 2021 were collected, including 18 males and 16 females, with a mean age of (45.8±14.1) years. The position of the tip of the screw trajectory on the anteroposterior and lateral films was divided in the same way. The number of screws in the corresponding 10 positions was counted, and CT analysis was used to determine whether each screw penetrated the medial wall of the axial pedicle or the vertebral artery foreman. Results: The results of the imaging simulation screw placement study showed that the perforation rate of the vertebral artery foramen in region Ⅳ and Ⅴ was 75.0% (120/160) and 100% (160/160), respectively, while the perforation rate of the medial wall of the axial pedicle in the region Ⅰ was 85.6%(137/160). The failure rate in regions Ⅱ and Ⅲ was relatively lower, and the performance of simulated screws located in the region a was better than those in region b. The perforation rates of the medial wall in regions (a-Ⅱ) and (a-Ⅲ) was 7.5% (6/80) and 0 (0/80), respectively, and the perforation rates of the vertebral foramen was 0 (0/80) and 21.3% (17/80), respectively. The retrospective imaging study also showed a higher rate of placement failure in regions Ⅰ, Ⅳ and Ⅴ, and relatively lower in regions Ⅱ and Ⅲ. There were total of 15 screws in region a-Ⅱ and a-Ⅲ, and no destruction of the medial wall of the axial pedicle and the vertebral artery foreman occurred there. Conclusions: Regions a-Ⅱ and a-Ⅲ are the "safety areas" of the tip of the pedicle screw trajectory in the axial vertebra. By analyzing the tip of the pedicle screw trajectory on the anteroposterior and lateral radiographs, the operator can determine the reasonable trajectory of axial pedicle screw placement, prevent the injury of the cervical spinal cord and vertebral artery, and reduce the risk of operation.

Association between kinking of the cervical carotid or vertebral artery and ischemic stroke/TIA.

IntroductionKinking of the cervical carotid or vertebral artery is a common structural abnormality in patients with cerebrovascular disease. However, there is no consensus about the relationship between kinking and ischemic stroke/TIA. We aim to determine the effect of arterial kinking on ischemic stroke/TIA.MethodsA retrospective study was performed on patients who underwent cerebral angiography with DSA between January 2014 and December 2018. Demographic information and comorbidities were recorded. Each anatomical circulation system was defined as an observation unit. Kinking and stenosis of each circulation unit were recorded. Ischemia stroke or TIA within 6 months and its location were assessed as an outcome. Logistic regression with a generalized estimating equation approach was used for the analysis.ResultsA total of 1,062 patients (mean age 57.9 ± 14.5 years, 740 males and 322 females) were included in the study. Of the patients, 369 (35%) had kinking and 771 (73%) had ischemic stroke/TIA. There were 110 left anterior, 90 right anterior, and 308 posterior circulation units, among which 343 had mild, 160 had moderate, and 243 had severe kinking. Multivariate regression analysis showed that ischemic stroke/TIA was associated with severe kinking (OR 1.39, 95% CI 1.03–1.88, P = 0.03). Posterior circulation was more vulnerable to acute ischemia than left anterior and right anterior circulation (OR 3.58, 95% CI 2.81–4.56, P < 0.0001).ConclusionSevere kinking of the cervical carotid or vertebral artery may be associated with a higher risk of ischemic stroke/TIA, especially when the kinking is located in the posterior circulation.

A case of Bow hunter's syndrome due to cervical rotation and vertebral artery dissection

A case of Bow hunter's syndrome due to cervical rotation and vertebral artery dissection

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes

A single-center, retrospective review between 2011 and 2018. A total of 156 patients were treated for isolated blunt vertebral artery injuries (16 bilateral) and underwent computed tomography angiography within 24 hours of presentation. Injury location was classified as: V1 = subclavian artery origin to the entrance into the C-6 transverse foramen; V2 = within the C2-C6 transverse foramen; V3 = from the C2 foramen to the foramen magnum dura; V4 = intradural. There were 79 grade I (≤25% luminal stenosis), 39 grade II (>25% luminal stenosis), 5 grade III (pseudoaneurysm), 49 grade IV (occlusion), and 0 grade V (extravasation or arteriovenous fistula) injuries. Three strokes were detected before treatment initiation. Most patients (135) were treated with aspirin alone, 2 with heparin, and 1 with Plavix, and 18 did not receive treatment (grade I injuries or required multiple surgeries for other problems). Only two patients were switched from aspirin to anticoagulation for injury progression. No strokes were detected during hospitalization for any other patient. The risk of stroke after blunt cervical vertebral artery injury is low. Aspirin is efficacious in grade I and IV injuries, but there are limited data regarding grade II and III injuries.

The cerebellum role in arterial hypertension

The consideration of the functioning body as a dissipative structure leads to the assumption of the existence of a regulative system, that through the feedback system keeps homeostasis. We already know the location of parameters’ detectors as well as the place of data analysis. Some information is available on how the system reacts to parameters’ change by signals distribution all over the body. This information is available for certain species. Quite often such information is gathered about the human body. Simple logic suggests, that if something interferes with the input of correct information, the system will eventually start to distribute incorrect signals and as a result this will lead to dysfunction.If we consider the cause of arterial hypertension (AHT) from this angle we inevitably meet with the blocking of information flow to the rhomboid fossa of the cerebellum through cervical vertebral arteries due their clamping by the damaged cervical cartilage. The data on the correlation of arterial blood pressure (BP) with linear blood flow through cervical vertebral, not carotid arteries is demonstrated. Available data supported the hypothesis as well as the data which should be collected to additionally support it are discussed.

Association of the RNF213 p.R4810K Variant With the Outer Diameter of Cervical Arteries in Patients With Ischemic Stroke

Background We investigated the impact of the p.R4810K variant of RNF213 (ring finger protein 213) gene, a susceptibility gene of moyamoya disease in East Asia, on the outer diameter of cervical parts of carotid and vertebral arteries (VAs). Methods We examined consecutive Japanese patients with ischemic stroke who underwent carotid ultrasonography between 2015 and 2019. Patient background and the carotid ultrasonography‐measured outer diameter of extracranial cervical arteries, including the common carotid artery, internal carotid artery, external carotid artery, and cervical VA, were compared between variant carriers and noncarriers. Outer diameters of each artery were defined as the mean distance from far to near wall adventitia of right and left target arteries using carotid ultrasonography. The average diameter of both cervical portions of common carotid arteries, internal carotid arteries, external carotid arteries, and the dominant side diameter of both cervical VAs were used. Results Of the 617 adult patients (204 women; median age, 74 years) analyzed, 26 (4.2%) carried the RNF213 p.R4810K variant. Variant carriers were significantly younger ( P &lt;0.01) and had more frequent steno‐occlusion of the M1 segment of the middle cerebral artery ( P &lt;0.01). Multivariate logistic regression analysis showed that variant carriers had significantly smaller mean diameters in the common carotid artery (7.25 versus 8.22 mm; adjusted odds ratio [aOR] per 1 mm decrease, 2.94; 95% CI, 1.69–5.00), cervical internal carotid artery (4.99 versus 5.55 mm; aOR, 1.66; 95% CI, 1.03–2.70), and cervical VA (3.55 versus 4.10 mm; aOR, 2.56; 95% CI, 1.33–4.76) than noncarriers. Mean diameters of the common carotid artery (aOR, 3.44; 95% CI, 2.08–5.88) and cervical internal carotid artery (aOR, 2.04; 95% CI, 1.23–3.33) and the dominant diameter of the cervical VA (aOR, 3.23; 95% CI, 1.72–5.88) were also smaller in variant carriers even when the analysis was restricted to patients without bilateral steno‐occlusion in target vessels or intracranial arteries distal to target vessels. Conclusion RNF213 p.R4810K variant carriers have smaller cervical arterial outer diameters in both anterior and posterior circulations than noncarriers with ischemic stroke. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02251665.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes.

Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.

Alteration of Relative Rates of Biodegradation and Regeneration of Cervical Spine Cartilage through the Restoration of Arterial Blood Flow Access to Rhomboid Fossa: A Hypothesis.

We found the logical way to prove the existence of the mechanism that maintains the rates of biodegradation and regeneration of cervical spine cartilage. We demonstrate, that after we restore access to arterial blood flow through cervical vertebral arteries to rhomboid fossa it causes the prevalence of regeneration over biodegradation. This is in the frames of consideration of the human body as a dissipative structure. Then the recovery of the body should be considered as a reduction of the relative rates of decay below the regeneration ones. Then the recovery of cervical spine cartilage through redirecting of inner dissipative flow depends on the information about oxygen availability that is provided from oxygen detectors in the rhomboid fossa to the cerebellum. Our proposed approach explains already collected data, which satisfies all the scientific requirements. This allows us to draw conclusions that permit reconsidering the way of dealing with multiple chronic diseases.

Overview of Imaging Modalities in Stroke.

This article reviews common imaging modalities used in diagnosis and management of acute stroke. Each modality is discussed individually and clinical scenarios are presented to demonstrate how to apply these modalities in decision-making. Advances in neuroimaging provide unprecedented accuracy in determining tissue viability as well as tissue fate in acute stroke. In addition, advances in machine learning have led to the creation of decision support tools to improve the interpretability of these studies. Noncontrast head computed tomography (CT) remains the most commonly used initial imaging tool to evaluate stroke. Its exquisite sensitivity for hemorrhage, rapid acquisition, and widespread availability make it the ideal first study. CT angiography (CTA), the most common follow-up study after noncontrast head CT, is used primarily to identify intracranial large vessel occlusions and cervical carotid or vertebral artery disease. CTA is highly sensitive and can improve accuracy of patient selection for endovascular therapy through delineations of ischemic core. CT perfusion is widely used in endovascular therapy trials and benefits from multiple commercially available machine-learning packages that perform automated postprocessing and interpretation. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) can provide valuable insights for outcomes prognostication as well as stroke etiology. Optical coherence tomography (OCT), positron emission tomography (PET), single-photon emission computerized tomography (SPECT) offer similar insights. In the clinical scenarios presented, we demonstrate how multimodal imaging approaches can be tailored to gain mechanistic insights for a range of cerebrovascular pathologies.

The Role of Digital X-Ray in Curative Effect and Nursing Evaluation of Cervical Spondylotic Radiculopathy.

The present study attempted to analyze the features of atlanto-occipital radiograph in patients with cervical spondylotic radiculopathy or vertebral artery type. In order to reduce the interference of human factors and the measurement error as much as possible, this experiment adopts the blind design and analyzes the digital format X-ray films by using the computer software ImageJ. Because the tangent line between the outer plates of the anterior and posterior margin of the foramen magnum was not accurately located on the X-ray film, the angle formed by the line between the saddle dorsal slope and the center point of the anterior and posterior nodule with a clear display was selected as the measurement method of the angle between the atlanto-occipital joints. The results showed that the lateral cervical curvature of the VCS group was 0.43 ± 0.51, and the lateral cervical curvature of the CSR group was 0.46 ± 0.49, both of which were significantly lower than the normal value (1.2 ± 0.5 cm). Patients in both groups had the characteristic of cervical curvature straightening. The changes of cervical curvature in overflexion and overextension positions can indirectly reflect the state of cervical motion. The anterior flexion neck curve of the VCS group was less than that of the CSR group (P < 0.05). Compared with the CSR group, VCS showed limited cervical anterior flexion movement. In this study, X-ray films of both CSR and VCS showed occipitocervical flexion and extension disorders, cervical curvature straightening, and lower cervical instability. In VCS, occipitocervical flexion and extension disorders were mainly manifested in atlantoaxial flexion disorders, while in CSR, atlanto-occipitocervical flexion and extension disorders were mainly manifested in atlantoaxial flexion disorders.

Os Odontoideum (OO): A Rare Cause of Cervical Myelopathy- Reports of two cases

Os odontoideum (OO) is a rare condition defined radiographically as an oval or round-shaped ossicle of variable size with smooth circumferential cortical margins representing the odontoid process that has no continuity with the body of second cervical vertebra (C2). Since the upper cervical spinal region is complex from anatomical point of view and has many vital structures passing in close relation to each other it is important to review this topic. If a person suffers from hyper mobile dens due to insuffiency of its ligamentous complex, it may cause translation of the atlas on the axis and may compress the cervical cord or vertebral arteries. However, patients with this condition may be asymptomatic or may be symptomatic of a variety of neurological deficits and vascular dysfunctions. There are cases where patients suffering from Os odontoideum became quadriplegic after a minor trauma. The treatment of both the asymptomatic and symptomatic characteristics of this condition has undergone changes over the past few decades. In our paper we present two cases who presented as spastic quadriplegia, then was diagnosed as Os odontoideum (OO) and treated.&#x0D; Bangladesh J Child Health 2020; VOL 44 (2) :118-121