Left Vertebral Artery Research Articles

Hyperacute thrombosis of a vertebral artery stent with a single missed dose of a P2Y12 inhibitor and poor stent wall apposition: illustrative case.

Iatrogenic vertebral artery injury during surgery can cause pseudoaneurysm, hemorrhage, thrombosis, ischemia, or death. Strategies to prevent cerebrovascular embolic complications include surgical ligation, endovascular stenting, and/or antiplatelet therapy. A 73-year-old female with a known right vertebral artery occlusion underwent a C2-3 laminectomy, complicated by left vertebral artery injury and occlusion with subsequent posterior circulation ischemia. She underwent immediate angioplasty and stenting of the injured artery with undersized drug-eluting stents. Dual antiplatelet therapy of aspirin 81 mg daily and ticagrelor 90 mg twice daily was initiated. On two occasions, more than 6 months after stenting, holding a single ticagrelor dose led to in-stent thrombosis and embolic stroke within hours of the missed dose. Lifelong therapy with ticagrelor was favored over further procedural intervention. It is recommended to prioritize optimal wall stent apposition with oversized stents in patients without collateral circulation. The risk of thromboembolism due to poorly apposed stents is very high, even in delayed (> 6 months) settings. Stent construct revision or bypass grafting may not be feasible or desirable options. For patients without wall apposition, endothelialization may not occur, necessitating lifelong P2Y12 inhibitor therapy to prevent recurrent thromboembolic events. https://thejns.org/doi/10.3171/CASE24296.

A case report of an Adachi-Williams type CG plus H aortic arch anomaly and implications for the development of the cervicothoracic circulation.

It is unclear whether the development of the branches of the subclavian artery is dependent on the proximal part of this artery since great vessel formation is partially regulated by haemodynamic stress. For example, the vertebral artery that usually arises from the subclavian artery might be affected by anomalies in the aortic arch branches. This uncertainty is partly due to the limited reports of highly anomalous cases of proximal and distal branching morphologies. Here, we report an Adachi-Williams type CG plus H aortic arch case found during student dissection and discuss the development of the cervicothoracic circulation. Here, we report an aberrant right subclavian artery that arose from the aorta distal to the left subclavian artery, via a retroesophageal course, whereas the right and left common carotid arteries arose from a short common trunk from the aorta (the carotid trunk) (Adachi-Williams type H). In addition, the left vertebral artery arose directly from the aortic arch between the carotid trunk and the left subclavian artery (Adachi-Williams type CG). Anomalies in the branching arteries from this aberrant right subclavian artery (the right vertebral artery, internal thoracic artery, thyrocervical trunk, costocervical trunk and thoracoacromial artery) were unidentifiable. The right vagus nerve directly innervates the laryngeal muscles without forming the recurrent nerve. The development of an aberrant right subclavian artery might affect haemodynamic stress in both the proximal and distal regions of the anterior limb region. The distal branching morphology, however, was normal, suggesting an independence of proximal and distal vasculature development. Since the concomitance of Adachi-Williams-type CG and H is rare, rather than sequentially develop, the distal arteries develop in a fine-tuned manner to adapt to anomalies in the proximal arteries.

Morphological characteristics and outcomes of aortic repair of acute type A aortic dissection occurring in patients with aortic arch branching variants.

To investigate the morphological characteristics and operative outcomes of acute type A aortic dissection (ATAAD) in patients with aortic arch variants. Of 616 patients with ATAAD, 97 (15.7%) had aortic arch variants, including bovine aortic arch (BAA, n = 66), isolated left vertebral artery (ILVA, n = 25), and aberrant subclavian artery (ASA, n = 6). The characteristics and outcomes were compared between the normal branching group (control, n = 519) and the total/individual arch variant groups. Compared to the control group, arch entry was more prevalent in the BAA (18.5% vs. 31.8%) and ILVA groups (44%) (both, P < 0.05), and right common carotid arterial occlusion was less common in the arch variant group (6.7% vs. 0%, P = 0.017). The in-hospital mortality (9.2% vs. 9.3%), new-onset stroke (7.3% vs. 7.2%), and 5-year survival (81.7% vs. 78.8%) did not differ markedly between the control and arch variant groups. Arch repair was performed in 28.9% (28/97) of the arch variant group using 3-4 vessel antegrade cerebral perfusion, with 3.8% in-hospital mortality and a 15.4% stroke rate, which were comparable to those of the control group. Aortic arch variants may influence tear location and involvement of the supra-arch vessels but may not affect postoperative outcomes.

Single-branched stent-graft with on-table fenestration for the management of zone 2 landing TEVAR with an isolated left vertebral artery: a pilot study

BackgroundIt is challenging to simultaneously conduct total endovascular repair and reconstruct the left subclavian artery (LSA) and isolated left vertebral artery (ILVA) in patients who had an ILVA and required zone 2 anchoring. This pilot study reported the initial application experience of thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing for aortic arch reconstruction in patients with ILVA.MethodsThis study was a retrospective consecutive single-center case series analysis, which involved four patients with ILVA who required zone 2 anchoring and received TEVAR combined with a single-branched stent graft and concomitant on-table fenestration between March 2021 and December 2022.ResultsThe postoperative follow-up period was 6–27 months, and no postoperative deaths or other primary complications occurred. There were no signs of a stroke or spinal cord ischemia, as well as no chest or back pain. The postoperative computed tomography angiography showed unobstructed ILVA and LSA, no stent stenosis and displacement, and no signs of endoleak.ConclusionThe outcome suggested that this technique might be a feasible, safe, and alternative treatment for such patients. Further studies with larger samples and longer follow-up periods are needed to confirm our findings.

Native valve endocarditis caused by Corynebacterium striatum without underlying structural heart disease or indwelling cardiovascular medical devices: a case report

BackgroundCorynebacterium striatum (C. striatum) is a gram-positive, anaerobic bacillus found both environmentally and in human skin and nasal mucosa flora. It is reportedly the etiologic agent of community-acquired and nosocomial diseases and is significantly associated with bacteremia and medical endovascular devices. This is the rare case of mitral valve native valve endocarditis (NVE) caused by C. striatum occurring in a young adult without underlying structural heart disease or indwelling cardiovascular medical devices successfully treated with multidisciplinary therapy.Case presentationThe patient was a 28-year-old female with no medical history. She was transferred our hospital due to sudden onset of vertigo and vomit. A computed tomography on day 2 revealed the hydrocephalus due to the cerebellar infarction, and she underwent posterior fossa decompression for cerebellar infarction. An angiography on day 8 revealed a left vertebral artery dissection, which was suspected be the etiology. Afterwards, a sudden fever of 39 degrees developed on day 38. She was diagnosed with aspiration pneumonia and treated with ampicillin/sulbactam but was still febrile at the time of transfer for rehabilitation. Treatment continued with levofloxacin, the patient had no fever decline, and she was readmitted to our hospital. Readmission blood cultures (3/3 sets) revealed C. striatum, and an echocardiogram revealed an 11 mm long mitral valve vegetation, leading to NVE diagnosis. On the sixth illness day, cardiac failure symptoms manifested. Echocardiography revealed mitral valve rupture. She was transferred again on the 11th day of illness, during which time her mitral valve was replaced. C. striatum was detected in the vegetation. Following surgery, she returned to our hospital, and vancomycin administration continued. The patient was discharged after 31 total days of postoperative antimicrobial therapy. The patient experienced no exacerbations thereafter.ConclusionsWe report the rare case of C. striatum mitral valve NVE in a young adult without structural heart disease or indwelling cardiovascular devices.Clinical trial numberNot applicable.

Vertebral artery pseudoaneurysm: a rare cause of posterior circulation infarction in a middle-aged man.

Pseudoaneurysm of the vertebral artery is a rare cause of posterior circulation stroke. Treatment for this condition can be achieved through microscopic surgery or endovascular therapy. We report a case of a 36-year-old middle-aged male patient who presented with left limb numbness as the sole complaint. On a magnetic resonance imaging examination, multiple infarcts were observed in the left cerebellar tonsil. A subsequent head and neck computed tomography angiography examination led to the diagnosis of a pseudoaneurysm in the left vertebral artery. Following standard antiplatelet therapy, the patient underwent endovascular intervention. The patient's left limb numbness gradually subsided after surgery. A follow-up angiography performed 1 week after discharge showed no recurrence. These findings suggest that covered stent placement is an effective method of treating pseudoaneurysm of the vertebral artery.

A case report of high cervical spinal infarction after stenting with severe stenosis at the beginning of left vertebral artery.

Spinal cord infarction is an uncommon nervous system disorder. We present a case of high cervical cord infarction caused by stenting of the origin of the left vertebral artery (VA). The incidence of spinal cord infarction is minimal, and it must be distinguished from a number of other disorders. The diagnosis is primarily based on imaging, clinical symptoms, and history. Currently, there is no focused treatment for spinal cord infarction. Thrombolysis, high-dose glucocorticoid shocks, tube dilatation to promote circulation, and nutritional neurotropic medicines given early in the course of the disease can all help to slow the disease's progression. There is no agreement on the etiology, diagnosis, or therapy options for these people. On October 7, 2023, an 81-year-old man was admitted to the hospital primarily for recurrent chest tightness and pain that had persisted for more than 2 years and 1 month. Cerebral angiography upon admission revealed significant blockage of the right VA and stenosis of the left vertebral arterial origin. Six days following admission, a drug-eluting stenting procedure was carried out under local anesthesia to open the left VA origin via the femoral artery. Following the procedure, the patient experienced a progressive loss of muscle strength in all 4 limbs and paraplegia below the cervical 3 spinal cord. One week following the procedure, the patient was released from the hospital. After the procedure, the patient was released 1 week later. After the procedure, the patient's symptoms persisted for a month. High awareness for high cervical cord infarction is required when neck discomfort and limb weakness with progressive progression arises after surgery. Complications of high cervical cord infarction following stenting for stenosis of VA origin are uncommon in clinical settings. Patients' prognoses can be improved by prompt diagnosis and care.

Exploring the atlantic part of the vertebral artery in the South Indian population and its implications in spine surgery.

A descriptive, quantitative cross-sectional study of the atlantic part (V3) of the vertebral artery (VA). This study aimed to bridge the research gap in the morphometry of the V3 segment of the VA in the South Indian population. The microsurgical anatomy of this segment of the VA has been explored in various populations, and a thorough understanding of the anatomy and course of the VA, particularly the V3 segment, is essential to prevent iatrogenic complications. Several computed tomography studies but a few cadaveric studies have explored the V3 segment of the VA in the South Indian population. This study examined 40 VAs from 20 embalmed cadavers that were obtained from the voluntary donation program, and Institutional Ethical Clearance was obtained before the study. The length, diameter, and angle of the vertical, horizontal, and exit parts of the V3 segment of the VA were documented after its exposure. The mean lengths of the right and left VAs on each part were nearly similar, except for the mean length of the horizontal part (right: 38.937 mm, left: 40.237 mm) and total length of the V3 segment (right: 66.870 mm, left: 70.350 mm). These morphometric parameters are essential to spine surgeons who intend to operate on a small part (vertical, horizontal, or exit part) of the V3 segment of the VA. The mean values of the parameters obtained in this study give average measurements or safe limits to surgeons for safe surgical procedures such as the occipital condyle screw technique and C1 laminectomy.

The impact of an anomalous third segment of the vertebral artery on bypass surgery: a case report and literature review.

The horizontal part of the third segment (V3) of the vertebral artery (VA) is a critical anastomotic site for bypass procedures involving either donor or recipient vessels. It is rare for the V3 segment to deviate from its typical course of passing through the atlanto-transverse foramen. V3 anomaly encountered in occipital artery (OA)-V3 bypass surgery has not been previously reported. Here, we present a case involving a patient undergoing bypass surgery due to recurrent post-stent occlusion at the first segment (V1) of the left VA. During the operation, it was noted that the V3 horizontal segment could not be identified within the left VA groove, leading to initial suspicion of left V3 disuse atrophy attributed to prolonged chronic ischaemia. Consequently, there was a need to modify the operative method and to transition from an OA-V3 bypass to an OA-posterior inferior cerebellar artery bypass. Post-operative computed tomography angiography confirmed that indeed, the left V3 did not traverse through the transverse foramen of the atlas and instead entered the dural membrane between the first cervical vertebra (C1) and the second cervical vertebra (C2).

Weaning failure due to isolated residual diaphragmatic paralysis after cervical spinal cord ischemia following aortic surgery- a case report

BackgroundBilateral diaphragmatic dysfunction can lead to dyspnea and recurrent respiratory failure. In rare cases, it may result from high cervical spinal cord ischemia (SCI) due to anterior spinal artery syndrome (ASAS). We present a case of a patient experiencing persistent isolated diaphragmatic paralysis after SCI at level C3/C4 following thoracic endovascular aortic repair (TEVAR) for Kommerell’s diverticulum. This is, to our knowledge, the first documented instance of a patient fully recovering from tetraplegia due to SCI while still exhibiting ongoing bilateral diaphragmatic paralysis.Case presentationThe patient, a 67-year-old male, presented to the Vascular Surgery Department for surgical treatment of symptomatic Kommerell’s diverticulum in an aberrant right subclavian artery. After successful surgery in two stages, the patient presented with respiratory insufficiency and flaccid tetraparesis consistent with anterior spinal artery syndrome with maintained sensibility of all extremities. A computerized tomography scan (CT) revealed a high-grade origin stenosis of the left vertebral artery, which was treated by angioplasty and balloon-expandable stenting. Consecutively, the tetraparesis immediately resolved, but weaning remained unsuccessful requiring tracheostomy. Abdominal ultrasound revealed a residual bilateral diaphragmatic paralysis. A repeated magnetic resonance imaging (MRI) 14 days after vertebral artery angioplasty confirmed SCI at level C3/C4. The patient was transferred to a pulmonary clinic with weaning center for further recovery.ConclusionsThis novel case highlights the need to consider diaphragmatic paralysis due to SCI as a cause of respiratory failure in patients following aortic surgery. Diaphragmatic paralysis may remain as an isolated residual in these patients.

Nape seven needles combined with pressing moxibustion for cervical vertigo: a randomized controlled trial

To observe the clinical effect of nape seven needles combined with pressing moxibustion for cervical vertigo (CV). A total of 70 patients with CV were randomized into an observation group and a control group, 35 cases in each group. In the observation group, nape seven needles combined with pressing moxibustion was delivered, once a day, 6 times a week, for consecutive 2 weeks. In the control group, betahistine hydrochloride tablet and aceclofenac dispersible tablet were given orally, for 2 weeks and 3 days respectively. Before and after treatment, the evaluation scale for cervical vertigo (ESCV) score was observed, the plasma levels of neuropeptide Y (NPY), endothelin-1 (ET-1) and calcitonin gene related peptide (CGRP) were detected, the hemorheologic and hemodynamic indexes were measured, and the clinical efficacy was evaluated after treatment in the two groups. After treatment, the scores of dizziness, daily life and work ability, psychological and social adaptability, and headache, as well as the total scores of ESCV were increased compared with those before treatment (P<0.01, P<0.05) in the two groups, and the score and total score of neck and shoulder pain of ESCV was increased compared with that before treatment (P<0.01) in the observation group; each sub-item score and total score of ESCV in the observation group were higher than those in the control group (P<0.01, P<0.05). After treatment, the plasma levels of NPY and ET-1 were decreased compared with those before treatment (P<0.01), while the plasma levels of CGRP were increased compared with those before treatment (P<0.01, P<0.05) in the two groups; the plasma levels of NPY and ET-1 in the observation group were lower than those in the control group (P<0.01), the plasma level of CGRP in the observation group was higher than that in the control group (P<0.01). After treatment, the whole blood high shear viscosity, plasma viscosity and whole blood low shear viscosity were decreased compared with those before treatment (P<0.01, P<0.05), the mean velocity of basilar artery (BA), left vertebral artery (LVA) and right vertebral artery (RVA) were increased compared with those before treatment (P<0.05) in the two groups; the whole blood high shear viscosity, plasma viscosity and whole blood low shear viscosity in the observation group were lower than those in the control group (P<0.01), and the mean velocity of BA, LVA and RVA in the observation group were higher than those in the control group (P<0.05). The total effective rate in the observation group was 91.4% (32/35), which was superior to 71.4% (25/35) in the control group (P<0.05). Nape seven needles combined with pressing moxibustion can effectively alleviate the clinical symptoms, and improve the hemorheology and hemodynamics in CV patients.

Bow hunter’s syndrome due to an anomalous right vertebral artery origin and contralateral absence: a case report and literature review

BackgroundBow Hunter’s syndrome (BHS), also known as rotational vertebral artery occlusion (RVAO), is a rare condition characterized by dynamic vertebrobasilar insufficiency due to position-dependent occlusion of the vertebral artery (VA). In the existing literature, most cases of BHS are attributed to osteophytic compression originating from the occipital condyle or within the transverse foramen, often accompanied by anatomical abnormalities of the VA. However, cases presenting solely with VA anomalies in the absence of any cervical vertebral structural abnormality are rare. This case report presents a unique instance of BHS in a 56-year-old male, attributed to the anomalous origin of the right VA and the absence of the left VA, without cervical structural abnormalities.Case presentationThe patient exhibited symptoms like episodic dizziness and vertigo, which were exacerbated by rightward head rotation and alleviated upon returning to a neutral position. Diagnostic evaluation, including digital subtraction angiography, revealed that the right VA originated from the right common carotid artery and compression-induced stenosis of the right VA during head rotation. Conservative management, including avoidance of certain head movements and anti-arteriosclerosis medication, led to symptom resolution over a two-year follow-up period.ConclusionsThis report contributes to the understanding of BHS by highlighting a rare vascular anomaly presentation and incorporates a review of 14 similar case reports in the literature describing that an anatomical abnormality of the VA is mainly responsible for the pathology of BHS in the absence of cervical vertebral anomalies, thus emphasizing the need for careful diagnostic and management strategies.

Does ponticulus posticus affect vertebral artery diameter.

Ponticulus Posticus, atlantooccipital ligament ossification-induced anomaly, surrounds the vertebral artery and the first cervical nerve root. It is believed to wrap around the first cervical nerve root and the vertebral artery, causing compression. We hypothesized that it would also reduce the diameter of the vertebral artery. Between January 1, 2022, and December 31, 2022, cervical spine CT scans taken for any reason were retrospectively reviewed. The images of 1365 patients suitable for evaluation were evaluated by two expert radiologists in 3 dimensions. Among patients with PP, those who underwent cervical angiography were identified for vertebral artery diameter measurement. The average age of the 1365 individuals included in the study (732 males, 633 females) was 55.78 (± 18.85) with an age range of 1-96. Among this group, PP was detected in 288 individuals, resulting in a total prevalence of 21.1%. Right and left vertebral artery diameters were significantly lower in patients with complete PP compared to the absent group (p < 0,001, p < 0,001, respectively). Additionally, it was observed that width and height diameters and artery diameters were positively correlated in patients with Complete PP. Ponticulus posticus can cause vertebrobasilar insufficiency by reducing the diameter of the vertebral artery. Therefore, imaging and detailed evaluation of this region are important in symptomatic patients.

Vertebrobasilar system variations; Analysis with multi-detector CT angiography

Objective: The vertebrobasilar system provides vascular nutrition to the posterior part of the brain, medulla spinalis, medulla oblongata, and cerebellum. Anatomical variations in these vascular structures increase the incidence of thrombus and aneurysms in patients. This study examines the presence of anatomical anomalies in the vertebrobasilar system. Material and Methods: Retrospective CT angiogram images of 93 adult cases over 18 years of age who were examined for any reason in KSU, Training and Research Hospital Radiology Unit. Results: Vertebral artery hypoplasia was observed in 15% of the cases. Left dominance was observed in 64.2% of the cases, right dominance in 28.6%, and co-dominance in 7.2%. Vertebral artery duplication was not observed. Vertebral artery fenestration was observed in 2.1% of cases. Vertebral artery of flexible origin was detected in 7.5%. In 57% of cases with a variable origin, the vertebral artery originated as the second branch of the subclavian artery. The right vertebral artery originating from the brachiocephalic artery was seen in 14.2%, the left vertebral artery originating from the arcus aorta was seen in 14.2%, and the left aberrant vertebral artery was seen in 14.2%. Fenestration of the basilar artery was observed in 2.1%, and hypoplasia of the basilar artery in 1.1%. Fetal type PCA variation was observed in 35.4% of cases, bilateral fetal PCA in 3.2%, right fetal PCA in 17.2%, and left fetal PCA in 15%. PCA duplication was observed in 3.2%, SCA duplication in 16.1%, unpaired single SCA in 2.1%, and SCA fenestration in 1.1%. An unpaired single AICA was observed in 15%, duplication of AICA in 2.1%, hypoplastic AICA in 6.4%, and AICA originating from SCA in 1.1%. An unpaired single PICA was observed in 12.9%, hypoplastic PICA in 2.1%, basilar artery originating PICA in 9.6%, AICA originating PICA in 4.3%, and PICA duplication in 1.1%. Conclusion: This study provides a detailed analysis of anatomical variations in the vertebrobasilar system using multi-detector CT angiography. The findings highlight the prevalence and diversity of these variations, such as vertebral artery hypoplasia, dominance patterns, fenestrations, and origin variations. These variations have significant clinical implications, particularly in the context of interventional and surgical procedures, as well as in the diagnosis and management of cerebrovascular diseases. Recognizing and understanding these anatomical differences can aid clinicians in planning more effective treatment strategies, potentially reducing the risk of complications associated with thrombus and aneurysm formation. Further research with larger and more diverse populations is recommended to validate these findings and to explore the impact of these variations on clinical outcomes. Ultimately, this study contributes to the existing body of knowledge and underscores the importance of personalized approaches in the management of vertebrobasilar system anomalies.

Aberrant Origin of Left Vertebral Artery – Multidetector Computed Tomography Study

Background: The vertebral arteries originating from respective subclavian arteries are the major source of oxygenated blood to posterior cerebral circulation and supply the upper spinal cord, brain stem, cerebellum, and occipital lobes of the cerebrum. Paucity of radiological studies prompted us to undertake this study which aims to analyze the variations in origin of left vertebral artery (LVA). Materials and Methods: This is a retrospective cross-sectional study of contrast-enhanced computed tomography chest scans of 710 subjects retrieved from the archives of a single imaging center. Observations and Discussion: Normal origin of LVA from the left subclavian artery (LSA) in the root of the neck was noted in 90.56% and variant origin in 9.44% of cases. Four-branched aortic arch (AA) with direct AA origin of LVA was observed in 6.76% of cases. An atypical three-branched pattern with LVA origin between the bovine trunk (common trunk of brachiocephalic trunk [BCT] and left common carotid artery [LCCA]) and LSA was seen in 0.84% of cases. Common origin of both LVA and LSA from a vertebro-subclavian trunk (VST) is found in 0.98% of cases. LVA as the last branch of arch distal to LSA and LVA of arch origin associated with aberrant right subclavian artery were noted in 0.14% of cases each. A rare but important observation is the presence of two common trunks (bovine trunk (BCT + LCCA) and VST (LVA + LSA) in an atypical two-branched fashion found in 0.56%. Conclusion: Critical knowledge of variations of the origin of LVA is clinically relevant as such variations are more prone to vascular pathologies. Variations of the LVA are thought to alter cerebral hemodynamics and can produce cerebral dysfunction. Preprocedural knowledge of such variations aids in the successful accomplishment of catheterization of LVA and avoids complications during neuroradiological interventions and surgical procedures.

Vertebral Artery Dissection with Cerebellar Infarction Due to Sudden Head Turning: Case Report

Abstract A 27-year-old man upon quickly turning his head experienced sudden dizziness, unilateral limb weakness, neck pain, and paralysis. He was transported to the emergency department by ambulance. Computed tomography (CT), computed tomography angiography (CTA), and magnetic resonance imaging (MRI) of the brain identified a left vertebral artery dissection with cerebellar infarction without subarachnoid hemorrhage (SAH). The patient’s blood pressure was controlled, and he was placed on bed rest, but no surgical intervention was undertaken. A cerebral angiography performed two months after the dissection found the previously stenosed site fully patent with no further stenosis. Our case suggests that for extracranial vertebral dissection, the patient must be first checked for intracranial SAH, and in its absence, conservative treatment can be considered. Many studies have examined surgical intervention to address vertebral artery dissection; however, our case report presents a literature review regarding suitability for surgery in these patients.

Vertebral Artery Pseudoaneurysm After Extreme Lateral Transcondylar Transodontoid Approach for Clival Chordoma: 2-Dimensional Operative Video

Chordomas can be treated surgically, with radiotherapy, and more recently, chemotherapy. 1,2 A 22-year-old female patient presented with recurrence of a clival chordoma, after subtotal resection at an outside institution 3 months prior. MRI showed a predominantly midline lesion at the craniocervical junction with significant lateral extension eccentric to the left. A 3-staged operation was planned. A redo-endoscopic endonasal transclival transodontoid approach 3-5 was used to resect the midline component, followed by an extreme lateral transcondylar transodontoid approach with transposition of the ipsilateral vertebral artery followed by drilling of the ipsilateral occipital condyle and C1 lateral mass to resect the lateral component, followed by occiput to C3 fusion given the induced craniocervical instability. Careful subperiosteal dissection with preservation of the periosteal sheath overlying the vertebral artery was performed. There was no overt evidence of vertebral artery injury intraoperatively or on immediate postoperative imaging. However, 3 weeks later, the patient presented with blood from the oral/nasal cavity. Computed tomography angiography showed an unexpected left vertebral artery pseudoaneurysm. Pseudoaneurysms can develop after microtears in the muscularis layer. 6-8 Management is based on size, location, and vertebral artery dominance. 9,10 This pseudoaneurysm was coiled. Postcoiling, the patient had left hypoglossal palsy. We demonstrate the step-by-step technique of an extreme lateral transcondylar transodontoid approach for a clival chordoma and the unfortunate complication of a vertebral artery pseudoaneurysm with discussion of its etiology and management options for this potentially devastating complication. The patient consented to the procedure/publication. Institutional Review Board approval not obtained as the patient was deidentified, and no additional risk is posed by the publication of this video.

Management of Anomalous Left Vertebral Artery During Open Total Arch Replacement

BackgroundAn anomalous left vertebral artery (aLVA) can complicate aortic arch surgery. We examined the safety of various aLVA revascularization strategies during open total arch replacement. MethodsWe retrospectively evaluated 92 patients undergoing total arch replacement from January 2018 to May 2023 and identified 11 patients with aLVA. A comparison group (n = 31) with conventional 3-branched anatomy was selected by 3:1 matching on age, sex, circulatory arrest time, and operative mortality. Forty-two patients were selected for analysis. The primary outcome was perioperative stroke within 30 days. Secondary outcomes included spinal cord ischemia and long-term stroke. ResultsPatients with aLVA had an average age of 53 ±16 years. Indications included Stanford type A dissection (n = 4), chronic dissection with aneurysmal degeneration (n = 4), and primary aneurysmal disease (n = 3). The aLVA was reconstructed by transposition to the left carotid (n = 2) or subclavian (n = 8). In 1 case, partial zone 2 arch replacement was performed proximal to the aLVA and manipulation was not required. Total arch replacement with frozen elephant trunk was performed in 8 of 11 cases. No postoperative mortality was observed. One patient experienced transient postoperative stroke (9% vs 9%, P = 1.00). One patient received lumbar drain for suspected spinal cord ischemia (9% vs 7%, P = 0.59). One patient experienced stroke 6 months post operation. One-year patency of transposition was 100%. ConclusionsThe presence of aLVA does not impact outcomes of open arch surgery. Our strategy to preserve the aLVA may be preferable to simple ligation. We describe several safe and feasible approaches for reimplantation of this anomalous variant.

Strain of the vertebral artery during passive neck movements and spinal manipulation of the cervical spine: An observational study

BackgroundNeck pain is a common condition, and a frequent treatment is chiropractic cervical spinal manipulation therapy (cSMT). However, cervical spinal manipulations have been associated with excessive cervical artery elongations, allegedly causing arterial dissection leading to stroke. PurposeThe primary purpose of this study was to quantify the total vertebral artery elongations during cSMT, and secondarily, quantify the vertebral artery elongations during the pre-manipulative orientation of the head and neck and the subsequent elongations during the actual thrust. MethodsVertebral artery strains were measured at the cervical levels C0–C1, C1–C2, and C2–C3 using piezoelectric crystals that were sutured to the wall of the left and right vertebral artery in three cadavers. Vertebral artery strains were measured continuously for a full set of passive range of motion testing and for the chiropractic spinal manipulation. FindingsFor the range of motion testing, the greatest average vertebral artery strains at the C0–C1 level were 6.9% for ipsilateral flexion-rotation, at the C1–C2 level 4.3% for contralateral rotation, and at the C2–C3 level 3.7% for contralateral flexion-rotation. For the chiropractic spinal manipulation, the average maximal strains at the C0–C1, C1–C2 and C2–C3 levels were 1.3%, 0.1%, and 1.0%, respectively. The maximal average vertebral artery strains in the pre-manipulative phase were 0.5% and the corresponding maximal vertebral artery strains during the manipulative thrust was 1.1%. InterpretationPassive range of motion testing produced strains in the vertebral artery were 5.3 times (C0–C1), 7.2 times (C1–C2), and 3.7 times (C2–C3) greater than the corresponding strains during chiropractic spinal manipulation, suggesting that strains in the vertebral artery during chiropractic spinal manipulation were much smaller than the strains that can occur during normal everyday movements of the head and neck. Furthermore, vertebral artery strains in the pre-manipulative phase did not contribute to the peak strains on the contralateral vertebral artery and helped reduce strains on the ipsilateral side.

Aberrant origin of the left vertebral artery: clinical case and scientific literature

The variants in the origin of the trunks of the aortic arch are very heterogeneous. Among them, it is worth highlighting the variants that involve the origin of the vertebral artery and more specifically the left vertebral artery. We present the case of a 62-year-old patient in whom an aberrant vertebral artery was incidentally described in a computed tomography for oncological evaluation. This anatomical variant is asymptomatic in up to 5% of cases and can give rise to clinical problems of a vascular nature.