Ectatic Vertebral Artery Research Articles

Ectatic vertebral artery associated medullary compression treated with microvascular decompression: a case report and review of literature

BackgroundVertebral artery compression syndrome is a rare condition defined as the clinical presentation of dizziness, vertigo, ataxia, dysarthria, dysphagia, progressive or acute paralysis, hemisensory loss, and cervical myelopathy secondary to compression of the medulla and upper spinal cord by the vertebral artery.Case descriptionHere we describe a 57-year-old Mexican–American male with bulbar symptoms, positional vertigo, and diplopia. The patient’s symptoms were managed through microsurgical decompression of the medulla utilizing a far lateral transcondylar approach. The patient reported clinical improvement on follow-up.ConclusionThis case underscores the clinical complexity and heterogeneity of this rare neurovascular pathology and the importance of elucidating the pathophysiological mechanisms underlying the symptomatic presentation of vertebral artery compression syndrome.

Surgical Treatment of Hemifacial Spasm via Microvascular Decompression of a Large, Ectatic Vertebral Artery.

Hemifacial spasm is a neuromuscular disorder caused by compression of the facial nerve at the nerve root entry zone, often due to ectatic or aberrant vasculature. Pathologic compression of the nerve-brainstem interface results in involuntary, paroxysmal contractions of ipsilateral facial muscles that may cause considerable impairments in quality of life. For those with severe symptoms, have positive imaging demonstrating vascular compression, or who fail other management modalities, 1 2 3 4 microvascular decompression offers potential definitive treatment. 5 6 Traditionally, nonabsorbable packing agent is used to pack between the nerve and offending vascular structure. However, for large and more complex arterial structures, simple nonabsorbable padding is often not sufficient. In this operative video, we demonstrate microvascular decompression for intractable hemifacial spasm in a 52-year-old female using a specialized sling tacked to the petrous dura for management of a large, ectatic vertebral artery. Following a standard left retrosigmoid craniotomy, an atheromatous ectatic vertebral artery was identified. We fashioned a bovine pericardium sling around the vessel and used a permanent aneurysm clip to secure it to an incision portion of petrous dura. We subsequently identified potential additional facial nerve root compression by anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) branches, which were elevated and secured using Teflon felt packing. Following elevation of all three vessels, the lateral spread response resolved. At 2 weeks postoperatively, the patient reported substantial relief in her hemifacial spasms and endorsed highly improved quality of life.

Unilateral Holmes tremor associated with compression of the brainstem by an ectatic vertebral artery

Lesions affecting the Guillain–Mollaret triangle usually lead to palatal or oculopalatal tremors and occasionally Holmes tremors (HTs). We report two cases of unilateral HT without palatal tremor, secondary to brainstem compression by an ectatic vertebral artery. Unilateral HT may occur due to compression of the inferior olivary nucleus by an ectatic vertebral artery. This cause should be explored in patients who lack other obvious causes for tremor.

Endoscopic-Assisted Microvascular Decompression of Ectatic Vertebral Artery for Hemifacial Spasm: Operative Video and Technical Nuances

In this operative video atlas manuscript, the authors demonstrate the operative nuances and surgical technique for endoscopic-assisted microvascular decompression of a large ectatic vertebral artery causing hemifacial spasm. A retrosigmoid approach was performed and a large ectatic vertebral artery was transposed away from the root exit zone of cranial nerve VII ( Fig. 1 ). The lateral spread response disappeared, signifying adequate decompression of the facial nerve ( Fig. 2 ). The use of endoscopic-assistance during the microsurgical decompression was very useful to confirm the origin and also the resolution of neurovascular conflict. Postoperatively, the patient experienced immediate resolution of hemifacial spasm with normal facial nerve and hearing function. Written consent was obtained from the patient to publish videos, photographs, and images from the surgery. The link to the video can be found at: https://youtu.be/RlMz44uCDCw .

Microvascular Decompression and Nervus Intermedius Sectioning for the Treatment of Geniculate Neuralgia.

Objectives Demonstrate the surgical treatment of geniculate neuralgia via microvascular decompression and nervus intermedius sectioning. Designs Single case-based operative video. Setting Tertiary center with dedicated skull base team. Participants The patient is a 62-year-old female with a history of deep right-sided otalgia consistent with geniculate neuralgia. She failed appropriate medical treatment. Her magnetic resonance imaging (MRI) showed an ectatic vertebrobasilar system as well as an anterior inferior cerebellar artery (AICA) loop causing compression of the VII/VIII nerve complex in the cerebellopontine angle. Main Outcome Measures Resolution of right-sided otalgia. Results The patient underwent retrosigmoid craniotomy with microvascular decompression of the VII/VIII nerve complex and nervus intermedius sectioning. Intraoperatively, the patient was noted to have an ectatic vertebral artery and AICA that were compressing the root entry zone of the VII/VIII nerve complex. Microvascular decompression was performed of both the vertebral artery and AICA with Teflon. The nervus intermedius was sharply sectioned. The patient's postoperative course was uneventful with no complications. She continues to have resolution of her right sided otalgia at 6 months postoperatively. The link to the video can be found at: https://youtu.be/uRb_QfrINSk .

Dolichoectasia of the vertebrobasilar complex causing neural compression.

Dear Editor, We have read with great interest the paper of Yuh et al.[4] reporting a case of symptomatic hydrocephalus due to vertebrobasilar dolichoectasia (VBD) compressing the brainstem. Ectatic or pathologically enlarged vertebrobasilar arteries have been reported with increasing frequency and associated with several clinical syndromes. These include an assortment of cranial nerve syndromes, transient or permanent motor deficit, cerebellar dysfunction, central sleep apnea, ischemic stroke, hypertension, and hydrocephalus as reported in the paper by Yuh et al.[4] Others and we have also described pyramidal tract signs and cranial nerve nucleus dysfunction caused by vascular compression of the medulla oblongata by an elongated and ectatic vertebral artery and artery repositioning has proved to be an effective surgical treatment.[2,3] We agree with the authors that there is still uncertainty in the optimal treatment of VBD, since there has been no systematic review or long-term results from the different surgical interventions including microvascular decompression (MVD). However, to date, the MVD is the only interventional technique that is able to definitively treat such a pathological condition when associated with symptomatic neural compression. Neural compression by dolichoectatic vertebrobasilar arteries is an insidious clinical entity presenting several challenges to the neurosurgeon, because the operative procedure not only must be effective in relieving the symptoms, but also must preserve functioning neural and vascular structures. Therefore, the proper management should begin from the first observation of the patient affected by such an abnormality. A careful neurological examination is imperative to ensure that the patient's symptoms are attributable to vascular compression. Neuroradiological investigations are mandatory for diagnosis and surgical planning. With the advent of the magnetic resonance imaging technique, which, using specific three-dimensional sequences, has offered a good visualization of both cranial nerves and cerebral vessels, neurovascular compression disorders have been diagnosed with increasing frequency. In the clinical decision-making process, the neurosurgeon must determine whether the patient's symptoms are significant enough to warrant the surgical intervention. Finally, vessel repositioning must be performed carefully because of the elevated risk of injuring cranial nerves and the small perforating vessels of the vertebrobasilar system.[1] According to the literature and based on our experience, such a strategy can offer a complete clinical accomplishment with a functional respect of the neural structures.

Hemifacial spasm and jugular foramen syndrome caused by diametrically opposite aneurysms on the vertebral artery

Vertebral artery (VA) aneurysms commonly occur on a fusiform segment of the artery and have unusual appearances and characteristics [1]. They commonly present with symptoms of cranial nerve compression secondary to related dolichoectasia, mass effect or subarachnoid hemorrhage. In the setting of a VA aneurysm, hemifacial spasm occurs when the VA is ectatic or fusiform, while individual lower cranial nerve palsies have been reported in saccular and fusiform cases [1]. A simultaneous occurrence of these two clinical syndromes related to an aneurysmal VA has not been described. A 50-year-old lady presented with left-sided hemifacial spasm of 2-year duration and nasal regurgitation and altered phonation of 1-year duration. Both the symptoms were insidious in onset and were progressive. There was no history of facial pain or numbness, tinnitus or vertigo. Her neurological deficits included left sided IX, X nerve palsies. Examination of the other cranial nerves was normal. MRI of the brain showed a mildly ectatic vertebro-basilar artery (VBA) on the left side with compression on the VII–VIII nerve complex (Fig. 1a). Digital subtraction angiogram (DSA) revealed an ectatic left VA with a ventrolaterally pointing, distal 12 9 8 9 6 mm sized saccular aneurysm and a small blister aneurysm (3 9 3 mm) directed dorsomedially (Fig. 1b, c). At surgery via a far lateral craniectomy, the saccular aneurysm directed toward the jugular foramen was found arising proximal to origin of the posterior inferior cerebellar artery (PICA) which was draped on the aneurysm (Fig. 2a). It was clipped with a 10-mm angled ring clip, with the ring enclosing the VA (Fig. 2b). The clipped aneurysm was then opened and decompressed. The dorsally directed blister aneurysm compressing the facial nerve at its exit from the pons (Fig. 2b) was wrapped with muscle and dura. Teflon was interposed between the nerve and the ectatic VA segment. The risk of rupturing the nearby blister aneurysm and narrowing the ectatic VA precluded reconstruction of the VA with clips. Postoperatively, the patient was relieved of her hemifacial spasm, while her lower cranial nerve palsy remained status quo. An aneurysmal etiology is noted in 0.3–0.6 % of all cases of hemifacial spasm. The postulated pathogenesis is related to the compression of the root entry zone (REZ) of the facial nerve by the pulsations of the aneurysm. In 7.5–21 % of the cases an ectatic VBA is the causative factor [2]. A Pubmed search revealed 12 cases of VA aneurysms presenting with hemifacial spasm. One report describes Foville’s syndrome secondary to a dissecting VA aneurysm [3]. Our first-of-its-kind report demonstrates the simultaneous occurrence of hemifacial spasm and jugular foramen syndrome due to the mass effect of two aneurysms on an ectatic VA loop. Microsurgical clipping and debulking are performed for VA aneurysms causing brainstem compression and neurological deficits [4], while endovascular coiling is an optional in other cases [5]. In our case, the complex nature of the contiguous aneurysms on the VA segment and the need for decompression precluded endovascular intervention. S. V. Furtado (&) S. Thakar N. A. Saikiran A. S. Hegde Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), EPIP Area, Whitefield, Bangalore 560066, Karnataka, India e-mail: sunilvf@gmail.com

Anomalous vertebral artery compression of the spinal cord at the cervicomedullary junction

Background:Myelopathy from ectatic vertebral artery compression of the spinal cord at the cervicomedullary junction is a rare condition.Case Description:A 63-year-old female was originally diagnosed with occult hydrocephalus syndrome after presenting with symptoms of ataxia and urinary incontinence. Ventriculoperitoneal shunting induced an acute worsening of the patient′s symptoms as she immediately developed a sensory myelopathy. An MR scan demonstrated multiple congenital abnormalities including cervicomedullary stenosis with anomalous vertebral artery compression of the dorsal spinal cord at the cervicomedullary junction. The patient was taken to surgery for a suboccipital craniectomy, C1-2 laminectomy, vertebral artery decompression, duraplasty, and shunt ligation. Intraoperative findings confirmed preoperative radiography with ectactic vertebral arteries deforming the dorsal aspect of the spinal cord. There were no procedural complications and at a 6-month follow-up appointment, the patient had experienced a marked improvement in her preoperative signs and symptoms.Conclusion:Myelopathy from ectatic vertebral artery compression at the cervicomedullary junction is a rare disorder amenable to operative neurovascular decompression.

Downbeat Nystagmus Associated With Brainstem Compression by Vertebral Artery

Rarely, downbeat nystagmus can occur due to compression of the lower brainstem by the ectatic vertebral artery and be resolved by microvascular decompression. We present a case of a 67-year-old man with downbeat nystagmus associated with brainstem compression by ectatic vertebral artery. He presented with oscillopsia and vertigo. When he turned his head upward, his symptoms were aggravated and a gait disturbance occurred. Magnetic resonance imaging and computed tomographic angiography demonstrated compression of the medulla oblongata by the left ectatic vertebral artery and other medical causes of downbeat nystagmus were ruled out. Retromastoid craniotomy was performed and after lifting the vertebral artery off the medulla, a trough-shaped indentation in the lower brainstem was identified. The ectatic vertebral artery was repositioned and a Teflon was inserted between the brainstem and the ectatic vertebral artery. Postoperatively, downbeat nystagmus had disappeared.

Bulbar Compression by an Ectatic Vertebral Artery: A Novel Neurovascular Construct Relieved by Microsurgical Decompression

Brainstem compression caused by vascular abnormalities has rarely been reported in the literature. We describe five cases of large ectatic vertebral artery causing compression and distortion of the medulla oblongata with pyramidal tract signs and low cranial nerve dysfunction. Microvascular decompression by retracting the vertebral artery and anchoring it to the dura has been the treatment of choice. Five patients, four male and one female, presented with progressive myelopathic features and lower cranial nerve dysfunction, especially dysphonia and dysphagia. Four patients were affected by systemic arterial hypertension. Magnetic resonance imaging showed impingement of the right vertebral artery in three patients and the left vertebral artery in two patients, on the right and left lateral medulla, respectively. In two patients, hypoplasia of the contralateral vertebral artery was documented. All patients underwent neurovascular decompression of the medulla oblongata. The ectatic and tortuous vertebral artery was detached from the medulla, shifted away, and repositioned by anchoring to the nearby dura mater using a Gore-Tex vascular slip. Postoperatively, all patients but one had improvement of their previous neurological symptoms. Brainstem dysfunction caused by a tortuous ectatic vertebral artery might be less uncommon than expected. It should be considered a new distinct clinical entity, the real incidence of which needs to be carefully evaluated by an appropriate diagnostic protocol, which includes primarily magnetic resonance imaging with specific three-dimensional sequences. Awareness of this condition is necessary to ensure the appropriate treatment. Surgical microvascular decompression seems very effective.

Effect of frameless stereotaxy on the accuracy of C1-2 transarticular screw placement.

In recent studies some authors have indicated that 20% of patients have at least one ectatic vertebral artery (VA) that, based on previous criteria in which preoperative computerized tomography (CT) and standard intraoperative fluoroscopic techniques were used. may prevent the safe placement of C1-2 transarticular screws. The authors conducted this study to determine whether frameless stereotaxy would improve the accuracy of C1-2 transarticular screw placement in healthy patients, particularly those whom previous criteria would have excluded. The authors assessed the accuracy of frameless stereotaxy for C1-2 transarticular screw placement in 17 cadaveric cervical spines. Preoperatively obtained CT scans of the C-2 vertebra were registered on a stereotactic workstation. The dimensions of the C-2 pars articularis were measured on the workstation, and a 3.5-mm screw was stereotactically placed if the height and width of the pars interarticularis was greater than 4 mm. The specimens were evaluated with postoperative CT scanning and visual inspection. Screw placement was considered acceptable if the screw was contained within the C-2 pars interarticularis, traversed the C 1-2 joint, and the screw tip was shown to be within the anterior cortex of the C-1 lateral mass. Transarticular screws were accurately placed in 16 cadaveric specimens, and only one specimen (5.9%) was excluded because of anomalous VA anatomy. In contrast, a total of four specimens (23.5%) showed significant narrowing of the C-2 pars interarticularis due to vascular anatomy that would have precluded atlantoaxial transarticular screw placement had previous nonimage-guided criteria been used. Frameless stereotaxy provides precise image guidance that improves the safety of C1-2 transarticular screw placement and potentially allows this procedure to be performed in patients previously excluded because of the inaccuracy of nonimage-guided techniques.

Magnetic Resonance Angiographic Diagnosis of Ectatic Vertebral Artery

In the cervical spine, routine and contrast magnetic resonance (MR)- and computed tomography (CT)-based studies may fail to differentiate between an ectatic vertebral artery and a solid foraminal mass. A complete cervical and lumbar Myelo-CT scan in a 67-year-old female with lumbar stenosis revealed an incidental, left-sided C3-C4 foraminal mass. A vascular lesion was suspected when the MR study revealed the lesion to be a signal void. MR angiography confirmed an ectatic C3-C4 vertebral artery loop. The possibility of a vertebral artery anomaly should be considered in patients with asymptomatic lateral and foraminal cervical lesions on CT studies. In these patients, routine MR and MR angiography are necessary to demonstrate the status of the vertebral artery in the foramen.