Course Of Vertebral Artery Research Articles

Transverse and oblique course of the vertebral artery over the medullospinal junction.

The vertebral artery (VA) pierces the dura mater and continues with the intradural V4 segment. Once entered into the dura mater, the VA ascends from the infero-lateral to the antero-superior side of the medulla. Scarce reports of VAs compressing the medullospinal junction (MSJ) are available. We therefore aimed to determine the incidence of a course of the AV over the MSJ. One hundred sixty-two archived CT angiogram files were documented in the study. We recorded the cases in which the VA crossed the MSJ. We assessed the VA as dominant, non-dominant or co-dominant. In 32 cases (19.75%), we identified intradural AVs on the ventral side of the MSJs. The incidence of this course of the VA was 17.1% in males and 23.81% in females. Of the 32 cases, the VA was non-dominant in 6, dominant in 14, and co-dominant in 12. The VA course over the MSJ is not rare. Therefore, when specific neurological signs of MSJ or medulla compression are found, the course of the VA should be documented on CT or MRI angiograms.

A Novel Evaluation for Vertebral Artery Course Using 3D Magnetic Resonance Imaging with Computed Tomography -like Bone Contrast and Magnetic Resonance Angiography: A Proof of Concept Study

Vertebral artery (VA) injury poses a significant risk in cervical spine surgery, necessitating accurate preoperative assessment. This study aims to introduce and validate a novel approach that combines the Fast field echo that resembles a computed tomography using restricted echo spacing (FRACTURE) sequence with Time of Flight (TOF) Magnetic Resonance Angiography (MRA) for comprehensive evaluation of VA courses in the cervical spine. A total of eight healthy volunteers and two patients participated in this study. The FRACTURE sequence provided high-resolution bone images of the cervical spine, while TOF MRA offered non-invasive vascular imaging. Fusion images were created by merging FRACTURE and MRA modalities to simultaneously visualize cervical spine structures and VA courses. Board-certified orthopedic spine surgeons independently evaluated images to assess the visibility of anatomical characteristics of the VA course by Likert-scale. The FRACTURE-MRA fusion images effectively depicted the extraosseous course of the VA at the craniovertebral junction, the intraosseous course of the VA at the craniovertebral junction, the VA entrance level to the transverse foramen, and the side-to-side asymmetry of bilateral VAs. Additionally, clinical cases demonstrated the utility of the proposed technique in identifying anomalies and guiding surgical interventions. The integration of the FRACTURE sequence and TOF MRA presents a promising methodology for the precise evaluation of VA courses in the cervical spine. This approach improves preoperative planning for cervical spine surgery with detailed anatomy and is a valuable alternative to conventional methods without contrast agents.

Review of Thyroid Cartilage Compression of the Vertebral Artery

Thyroid cartilage compression of the Vertebral Artery (VA) has been implicated as a rare cause of Rotational Vertebral Artery Occlusion (RVAO). 10 cases have been reported in the literature. This has a higher tendency to affect males and younger patients than other forms of stroke. Patients present with multiple episodes prior to diagnosis. Radiologic studies prove crucial for confirming this condition. An aberrant VA course appears to be a necessary factor. All cases suffer from right side VA compression by the superior thyroid cornu. Conservative therapy with antiplatelet treatment is employed commonly. Most patients have definitive treatment with surgical resection of the right superior thyroid cornu. Theories proposed for these characteristics include VA dominance, structural variability in the thyroid cartilage between genders and also variable thyroid cartilage ossification. Given these findings, we propose the term “thyro-vertebral artery syndrome” for this condition.

C1–C2 Transarticular Screw with Sublaminar Wiring for Reducible Atlantoaxial Dislocation: Operative Technique and Surgical Nuances

Abstract Transarticular screw provides rigid C1 C2 fixation. It is associated with robust implant construct and high fusion rates. Combining sublaminar wiring provides rigid three point fixation. This technique can be safely considered in reducible AAD where a wide C2 isthmus along with a normal Vertebral artery course is present. Authors describe the technique in detail with indications, benefits over other similar procedures, short falls and detailed operative steps. “Pearls and Pitfalls” adds a fresh perspective to this less often considered procedure.

C2 Superior Facetal Osteotomy: A Novel Technique in Complex Craniovertebral Junction Surgery for C1 Lateral Mass Screw Placement.

Complex craniovertebral junction (CVJ) defects account for a considerable proportion of CVJ diseases. Given the heavily assimilated C1, an unfavorable C1-C2 joint orientation, an overriding C2 superior facet, a low-hanging occiput, and an abnormal vertebral artery course with a high-riding vertebral artery, placement of C1 lateral mass screws might be difficult. To address this, a novel technique for placing C1 lateral mass screws that avoid vertebral artery injury, low-hanging occiput, and overriding C2 superior facet was developed in this study. This approach enables firm fixation of C1-C2 even in difficult situations where the placement of the C1 lateral mass is challenging.

Arcuate foramen prevalence in South African subjects: A cadaveric study based on 120 atlas vertebrae

BackgroundThis study was a prospective cadaver-derived skeletal study looking at the skeletal remains of a modern human population. The complete arcuate foramen (AF) is an anatomical variant of the atlas vertebra with a complete osseous bridge over the groove for the vertebral artery (VA). Awareness of the anatomic variations of the atlas related to the course of the VA, such as the AF, is important because the course and variations of VAs are critical to spine surgeons. We aimed to detect the prevalence of AF in sub-Saharan African subjects. Materials and methodsWe analyzed the prevalence of AF in 120 atlas vertebrae from the Raymond A Dart Collection of the University of the Witwatersrand, Johannesburg, South Africa. ResultsTwelve (13.3 %) atlases of the 90 that were from sub-Saharan African ancestry subjects presented at least one AF: the presence of AF frequency was 6.7 % in the Sotho sample, 23.3 % in the Xhosa sample and 10.0 % in the Zulu sample. However, no significant difference was found in their distribution regarding the presence of AF ratios (p = 0.221). The AF frequency was 3.3 % in the South African Caucasian subjects. No significant differences were found in their distribution regarding the presence of AF ratios between the Caucasian and the Sotho (p = 1.000), Zulu (p = 0.612) and Xhosa (p = 0.052) samples. ConclusionsOur research shows a tendency for a higher AF presence in Xhosa subjects. It has increased the knowledge of the AF prevalence in sub-Saharan Africa, drastically increasing the population.

Bilateral Vertebral Artery Fenestration in a Case of Craniovertebral Junction Neurenteric Cyst: Implications for Surgical Planning

Abstract Vertebral artery fenestration (VAF) is a type of anomaly of the vertebral artery in which a segment of the vessel divides into two separate channels that join together later in the course. Neurenteric cysts are rare, congenital lesions arising within the spinal canal usually in the cervical region. Vertebral artery anomalies if not considered during operative planning can lead to iatrogenic injury. We report a case of a 5-year-old boy who presented with a history of acute onset, non-traumatic spastic quadriparesis. Examination revealed the presence of cervical neurenteric cyst present ventrally at C1–C3 level. Further workup revealed the presence of bilateral VAF with the fenestrated part going along the inferior aspect of the arch of atlas bilaterally. Surgical excision of the lesion was done taking into consideration the anomalous course of vertebral artery. VAFs are classified according to their location as intracranial or extracranial and according to the segment of the vertebral artery from which they arise (V1–V4). Iatrogenic injury to the vertebral artery has been reported during both anterior and posterior approaches to the cervical spine. Due consideration should be given to anomalous course of vertebral artery while planning the surgical approach in craniovertebral junction.

Analysis of hemodynamic changes in vertebral arteries and veins during functional tests with ultrasound monitoring

Aim to evaluate the correlation between the course of vertebral arteries and veins and the results of calculations of hemodynamic parameters during ultrasound with functional tests.
 Material and methods. In the observation, 252 volunteers were examined using Samsung SonoAce R7 and GE Logiq F6 equipment. The hemodynamics was studied at the level of the second segment of the vertebral arteries and veins at rest, when turning, tilting and lifting the head. The results were processed using Microsoft Excel 2007 with subsequent statistical analysis.
 Results. 504 vascular complexes were analyzed without taking into account the visualization side. When assessing the arteries, the highest maximum blood flow velocity was registered when lifting the head in women with a rectilinear course of the vessels. In the group of men with non-rectilinear course of vessels, the lowest average blood flow velocity was registered when tilting the head. The highest volume flow was recorded in case of non-rectilinear vascular course in women when lifting the head.
 For vertebral veins, the highest indicators of maximum and minimum venous blood flow rates were observed in men with a rectilinear course of vessels when lifting the head. The highest values of the average flow velocity and volume flow were noted in men who had a rectilinear course of the vessels.
 The maximum values of the calculated venous volume flow were registered in groups with rectilinear vascular course: in men up to 19.4214.85 ml/min. (Me 12.45 ml/min.), in women 18.52 15.30 ml/min. (Me 10.50 ml/min.).
 Conclusion. The data obtained by the study contributes to improving the software and analysis of individual changes during patient examination, helps to evaluate the effectiveness of treatment and rehabilitation, as well as to analyze multifactorial models.

Extreme Lateral Approach to the Craniocervical Junction, Operative Technique and Approach Essentials: 2-Dimensional Operative Video.

The extreme lateral approach is useful for both extradural and intradural anterior and anterolateral lesions at the lower clivus down to the level of C2. The patient is evaluated with MRI, computed tomography (CT), and an angiogram. Special attention is given to vascular (vertebral artery course, dominance, tumor feeders) and bony (occipital condyle, jugular tubercle, foramen magnum and extent of bony involvement) anatomy. The patient is positioned lateral with the head flexed and tilted down without axial rotation. A hockey-stick incision is performed, and the myocutaneous flap is raised. A retrocondylar craniectomy is performed. The extradural vertebral artery is exposed for proximal control. A C1 hemilaminectomy is performed. Cephalad/caudal exposure and drilling of the occipital condyle are determined per case. The dura is opened, and the vertebral artery is released at the dural entry point to facilitate the tumor removal. The tumor is debulked and delivered inferoventrally away from the neuroaxis and cranial nerves. After removing the tumor, the dura is closed using an allograft.The patients consented to the procedure and to the publication of their images. • Cranial nerve deficits• Craniocervical instability• Postoperative hydrocephalus• Postoperative pseudomeningocele. A transmastoid extension of the craniectomy allows access further rostrally in the clivus. For C1-2 chordomas, the approach is extended inferiorly, and the vertebral artery is mobilized out of the C1-2 transverse foramina. For tumors involving the joints, an occipitocervical stabilization is required.Images in video reused with permission as follows: image at 00:16 from Revuelta Barbero et al, Endoscopic endonasal transclival-medial condylectomy approach for resection of a foramen magnum meningioma: 2-dimensional operative video, Oper Neurosurg, 16(2), 2018, by permission from the Congress of Neurological Surgery; images at 00:30, and top image at 00:52 reused from Wen et al, Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach, J Neurosurg, 87(4), 1997, with permission from JNSPG; bottom images at 00:52 from Muthukumar et al, A morphometric analysis of the foramen magnum region as it relates to the transcondylar approach, Acta Neurochir, 147(8), 2005, by permission from Springer Nature.

Teaching Neuro Images : Dynamic vertebral artery insufficiency

A 20-year-old healthy man presented with transient right upper monoparesis and brain MRI (figure, A) demonstrated left thalamic infarct. He presented 2 weeks later with left hemiparesis at basketball practice and right thalamic infarct (figure, B). Stroke risk factor workup was unrevealing. Conventional angiography demonstrated normal left vertebral artery course (figure, C and E), but dynamic left vertebral artery occlusion during 36° rightward head turn (figure, D and F). Bow hunter syndrome, first described in an archer,1 is eponymous for positional occlusion of the vertebral artery. This is associated with strokes from dynamic hypoperfusion. The patient remains symptom-free 1 month after microsurgical clip sacrifice of the left vertebral artery.

Craniovertebral junction aneurysms

ObjectiveThe course of the vertebral artery and its relationship to the C0–1–2 structures render it particularly vulnerable to mechanical trauma. In the present study, we investigated the course of vertebral arteries along the craniovertebral junction (CJ) to cast light on the biomechanical aspects of aneurysm formation, focusing mainly on the relation of the vertebral artery injuries to the CJ bony landmarks. Herein, we report our experience with fourteen cases of craniovertebral junction vertebral artery (CJVA) aneurysms and their presentations, management, and outcomes. Materials and methodsWe extracted from 83 vertebral artery aneurysms only those 14 cases whose aneurysms were located at the C0–1–2. We reviewed all medical records, including operative reports and radiologic images. We divided the CJVA into 5 segments and then carefully reviewed the cases, largely focusing on the CJVA segments involved in the aneurysm. Angiographic outcomes were determined by angiography, which was scheduled at 3–6 months, 1, 2.5, and 5 years postoperatively. ResultsA total of 14 patients with CJVA aneurysms were included in the present study. 35.7 % had cerebrovascular risk factors, while 23.5 % had other predisposing factors such as an AVM, an AVF, or a foramen magnum tumor. Predisposing factors in the form of neck trauma, both direct and indirect, were identified in 50 % of cases. The segmental distribution of aneurysms was as follows: three (21.4 %) at CJV 1, one (7.1 %) at CJV 2, four (28.6 %) at CJV 3, two (14.3 %) at CJV 4, and four (28.6 %) isolated to the CJV 5 segment. Of the 6 indirect traumatic aneurysms, 1 (16.7 %) was located at CJV 1, 4 (66.7 %) were located at CJV 3 and 1 (16.7 %) was located at CJV 5. The 1/1 direct traumatic aneurysm (100 %) from the penetrating injury was located at CJV 1. 100 % of cases with cerebrovascular risk factors, the affected vessels were on the dominant side. 42.9 % of cases presented symptoms of a vertebrobasilar stroke. All 14 aneurysms were managed only endovascularly. 85.8 % of patients we implemented flow diverters only. 57.1 % of follow-up cases were completely occluded angiographically, and 42.9 % of cases were near-completely or incompletely occluded at 1, 2.5, and 5-year follow-ups. ConclusionsThe current article is the first report of a series of vertebral artery aneurysms located in CJ. Herein, the association of vertebral artery aneurysm, hemodynamics, and trauma is well established. We clarified all segments of the CJVA and showed that the segmental distribution of CJVA aneurysms significantly differs between traumatic and spontaneous cases. We showed that treatment with flow diverters should be the mainstay of CJVA aneurysm treatment.

Surgical Management Of Irreducible Atlanto-Axial Dislocation With OS Odontoideum And Klippel-Feil Syndrome.

Klippel-Feil syndrome (KFS) is the congenital fusion of two or more cervical vertebrae which is often associated with various other abnormalities in the cervical spine. Involvement the upper cervical segments leads to atlanto-axial instability which manifests as progressive neurological symptoms due to compression on the spinal cord. These cases pose a surgical challenge due the abnormal and unique anatomy of each patient. A 37-year-old patient presented with neck pain and cervical myelopathy due to a posterior subluxation of C2-3 fused segment over C4-6 fused segment. The patient had an os odontoideum, incomplete posterior arch of C1, anomalous course of vertebral artery and C3 hemi-vertebra. The patient was successfully managed with transoral odontoidectomy and occipeto-cervical fusion. Irreducible atlanto-axial dislocation in a patient with an abnormal upper cervical spine anatomy may require transoral decompression followed by posterior fusion.

Entrance and origin of the extracranial vertebral artery found on computed tomography angiography

To investigated morphological variability of vertebral artery (VA) origin and its entrance level into cervical transverse foramina by computed tomography angiography (CTA). To retrospectively investigated CTA of 223 subjects (446 VA courses). Investigated were origin of the VA and its level of entrance into vertebral transverse foramen with notification of the sex and side of variation. The VA entered the C6 transverse process in 91.70% of specimens (409 out of 446 VA courses). Abnormal entrance of VA was observed in 8.30% of specimens (37 VA courses), with the level of entrance into the C3, C4, C5, or C7 transverse foramen at 0.22%, 2.47%, 4.71% and 0.90% respectively. Comparably, the overall variability of abnormal origin of VA was 1.57% (7 out of 466 VA courses), in which the left vertebral arteries all arose from aortic arch. The variation rate of vertebral entrance rose up to 50% in abnormal origin subgroup. When comparing subgroups of subjects with normal and abnormal origin, there was significance difference in the frequency of entrance variation in the level of transverse foramen (p < 0.001). Abnormal entrance and origin of VA were observed in 8.30% and 1.57% of VA courses, which can be accurately appeared by CTA. Regarding to the subgroups of abnormal origin, the frequency of entrance variation was significantly increased in the level of transverse foramen compared to that of normal origin.

Transoral Odontoidectomy – Our Experience in A Limited-Resource Setup

Although posterior procedures are used for most cases of basilar invagination, transoral decompression is an important tool in complex deformities with severe degeneration and neural compression. Consecutive patients who underwent transoral odontoidectomy for basilar invagination and atlantoaxial dislocation at the neurosurgical unit of Lady Reading Hospital Peshawar between June 2016 and January 2022 were retrospectively included. Preoperative and postoperative neurological, clinical, and radiological parameters were recorded and compared. Of the 33 patients included in this study, 22 were men and 11 were women. The mean age was 23.4years±8.4years (mean±standard deviation). The most common presenting symptoms were gait abnormalities and neck pain. A total of 28 patients were treated for the first time, while 5 patients had prior posterior fusion. The mean distance of the tip of the dens above the chamberlain line was 8.9±4.2mm, while the mean anterior atlantodental interval was 6.5±2.1mm. Seven patients had an anomalous course of vertebral artery on at least one side. A total of 28 patients improved significantly, while 5 patients did not improve at the follow-up. The mean follow-up was 8.5months±6.3 (mean±standard deviation). The mean Nurick and Modified Japanese Orthopedic Association scores improved postoperatively (P < 0.05). Three patients underwent reoperation including one with vertebral artery injury. Three patients underwent tracheostomy. With proper patient selection, transoral odontoidectomy can be safely performed in a limited-resource setting.

Anomaly of the sixth cervical vertebra accompanied by atypical course of the vertebral artery in a dog

AbstractThe vertebral arteries, as the first branches from the subclavian arteries, normally enter into the transverse foramen of the sixth cervical vertebra in dogs. This case report presents the non‐standard course of the left vertebral artery and unilateral asymmetry of the sixth cervical vertebra in a 14‐year‐old female mixed breed dog. The anomaly was an incidental finding during the preparation of a corrosion cast prepared for educational and scientific purposes. The left sixth cervical vertebra transverse foramen and the ventral lamina were not developed. The left vertebral artery originated normally from the left subclavian artery, but atypically entered into the transverse foramen of the fifth cervical vertebra. On the right side, the anatomical structures of the sixth cervical vertebra and the course of the right vertebral artery were normally developed. To our knowledge, this is the first case of such an anomaly described in a dog.

The vertebral Artery Anomalous, Stenosis vs Hypoplasia as the leading cause of Stroke. An anatomical cross-Sectional Study of VA anomalies in Neck three-Dimensional computed Tomography Angiography

Introduction: A thorough understanding of the vertebral artery (VA) variations and course of the artery and its related branches could significantly enhance the efficacy and safety of interventions involving the neck and spine. Here, we aimed to investigate the incidence of various VA variations in individuals presenting with signs and symptoms of stroke with our neurology team. Material and Method: In this retrospective study we investigate CTA images of patients with signs and symptom of stroke who referred to specialized medical imaging centre. An experienced board-certified radiologist evaluated the CTA images, recording the characteristics of VA, regarding dominance and any possible anomalies. These included anomalous origin, anomalous route, anomalous branching, stenosis, hypoplasia, atresia, thrombosis, and dissection. All data were analyzed using SPSS version24 and Pearson Chi-Square and Fishers test used for anomaly and gender correlation. Results: A total of 125 patients (53.6% females; mean age, 60.7 (11-87)) were included. In the case of VA dominance, 66.4% of cases were co-dominant while 16.0% were right, and 12.8% were left dominant. Overall, males had more VA anomalies than females, 24.8% and 17.6%, respectively (in general, 42.4% of all participants) (p = 0.020). Among patients, 4.0% (n = 5) had an anomalous origin and anomalous branching was reported in 5 patients (4.0%). Among the variations, significant stenosis (18.4%) and hypoplasia (17.6%) were the most prevalent anomalies with the earliest one having the higher rate. While anomalous branching was reported in 5 patients (4.0%). Conclusions: VA variations are relatively common and should be addressed during procedures involving the neck region and would allow surgeons to avoid life threatening injury.

Vertebral Artery Course Variations and Implications in Craniovertebral Junction Surgeries.

Vertebral Artery Course Variations and Implications in Craniovertebral Junction Surgeries.

Aberrant origin of right vertebral artery from the arch of aorta.

We present a rare case of an aberrant right vertebral artery originating from the arch of aorta distal to the origin of the left subclavian artery. The incidence of this particular variant of aberrant origin of the right vertebral artery is extremely uncommon with only seventeen cases reported in literature to date. This case was incidentally detected on a staging positron emission tomography-computerized tomography (PET-CT) scan for lung cancer. We review the incidence, embryological mechanism, and clinical importance of this aberrant course of the right vertebral artery.

Morphometric Study of Foramina Transversaria in Cervical Vertebrae and its Clinical Significance

Introduction: The characteristic feature of the cervical vertebrae is the presence of Foramen Transversarium (FT) in the transverse process. This foramen usually contains vertebral artery (except in C7 vertebra), veins and sympathetic plexus. The deformity and variations of this foramen may result in derangement of neurovascular structures passing through it, which may lead to various symptoms. The aetiology of morphological variations is related to developmental factors, mechanical stress and variations in the course of vertebral artery. Some studies have been done on accessory FT, but few give detailed analysis of morphometric variations of FT in cervical vertebrae. Aim: The aim of the study was to examine the morphological and morphometric variations in the FT of cervical vertebrae (typical and atypical). Materials and Methods: This was a retrospectively designed osteological observational study. The duration of the study was six months, from Dec 2019 to May 2020. The study was conducted on 750 cervical vertebrae (265 typical and 485 atypical). In each cervical vertebrae, the FT was observed for the following parameters; shape, size, maximum anteroposterior diameter, maximum transverse diameter, area and number. Digital vernier caliper was used for morphometric measurements. Photographs were taken and archived. Descriptive analysis and evaluation was done with SPSS statistics programme. results: In 300 (40%) vertebrae, shape of the FT was bilaterally symmetrical and in 450 (60%) vertebrae, it was asymmetrical on both sides. It was observed that maximum anteroposterior diameter and transverse diameter were seen in C1 vertebrae. There was no significant statistical difference between the mean diameters of the left and right side. Maximum area was also seen in C1 vertebrae, with values of 34.76 mm2 on left and 34.84 mm2 on right. Out of the 750 cervical vertebrae, 113 (15%) showed an accessory FT in the transverse process. Amongst these, in 30 (4%) cervical vertebrae, the accessory FT were present bilaterally and in 83 (11%) seen on one side only. conclusion: The present study demonstrates that different cervical vertebrae (typical and atypical) show considerable morphological variations in terms of shape, size, area and number of FT. Awareness of such variations is of significance to anatomists, clinicians and surgeons.

Vertebral Artery Variation in Patients With Congenital Cervical Scoliosis: An Anatomical Study Based on Radiological Findings.

Observational, anatomical, radiological study. The aim of this study was to explore the incidence and type of vertebral artery (VA) variation in patients with congenital cervical scoliosis and approach their clinical importance during surgery. Congenital scoliosis of the cervical spine is usually sporadic and caused by a variety of bone structural anomalies. Most of the cases remain asymptomatic. Surgical intervention is the main management for patients with neurological compromise or with cosmetic demands. The operation involved more screw insertion and osteotomy than the regular degenerative cases. The incidence and pattern of VA variants in these patients have not been reported. Patients with congenital cervical scoliosis treated in our department were reviewed. We measured Cobb angle of cervical spine. We observed bilateral VAs and recorded variants. We measured their diameter in each segment through CT angiography. The bilateral diameter in each patient was then compared respectively. There is a total of 44 patients enrolled. The incidence of VA variation was 41% (18/44). Fifty percent (22/44) of patients had the dominant VA with no difference between concave side and convex side. Patients with a dominant VA had a larger Cobb angle than those who had not (30.25° vs. 23.24°, P < 0.05). The courses of VA were abnormal in 18 patients. Two patients had unilateral variant in V1 segment. Twelve patients had variants in V2 segment. Eight patients had variants in V3 segment. Three patients had VA variants in multiple sites. In patients with congenital cervical scoliosis, the dominance of VA is not related to the convex side or concave side, but patients with a dominance of VA have a larger Cobb angle. The incidence of variant in V2 and V3 segment is higher. A thorough evaluation of bilateral VAs is required before surgery. Extra cautions must be taken during surgery.Level of Evidence: 5.