Bilateral Vertebral Artery Occlusion Research Articles

Safety and efficacy of dynamic catheter-directed cerebral digital subtraction angiography for diagnosis of bowhunter syndrome spectrum disorders: A systematic review of the literature.

Dynamic catheter-directed cerebral digital subtraction angiography (dcDSA) is the gold standard for diagnosing dynamic vascular occlusion syndromes such as bowhunter syndrome (BHS). Nonetheless, concerns about its safety exist and no standardized protocols have been published to date. We describe our methodology and insights regarding the use of dcDSA in patients with BHS. We also perform a systematic literature review to identify cases of typical and atypical presentations of BHS wherein dcDSA was utilized and report on any procedural complications related to dcDSA. Our study included 104 cases wherein dcDSA was used for the diagnosis of BHS. There were 0 reported complications of dcDSA. DcDSA successfully established diagnosis in 102 of these cases. Thirty-eight cases were deemed atypical presentations of BHS. Fourteen patients endorsed symptoms during neck flexion/extension. In eight cases, there was dynamic occlusion of bilateral vertebral arteries during a single maneuver. Three patients had multiple areas of occlusion along a single vertebral artery (VA). An anomalous entry of the VA above the C6 transverse foramen was observed in four patients. One patient had VA occlusion with neutral head position and recanalization upon contralateral lateral head tilt. Our study highlights the safety and diagnostic benefits of dcDSA in characterizing the broad spectrum of BHS pathology encountered in clinical practice. This technique offers a powerful means to evaluate changes in cerebral blood flow and cervical arterial morphology in real time, overcoming the constraints of static imaging methods. Our findings pave the way for further studies on dcDSA to enhance cross-sectional imaging methods for the characterization of BHS and other dynamic vascular occlusion syndromes.

Embolization of an Intracranial Vertebral Artery Aneurysm via the Deep Cervical Artery.

Treatment of vertebral artery aneurysms can be challenging due to the unusual vascular anatomy or unfeasibility of traditional endovascular techniques. We describe a novel approach for endovascular treatment of a ruptured intracranial vertebral artery aneurysm with bilateral vertebral artery occlusions and hypoplasia of the posterior communicating arteries. Successful coil embolization was performed using a collateral pathway for microcatheterization via anastomosis between the deep cervical artery and the vertebral artery. This case report highlights a novel alternative endovascular treatment approach for vertebrobasilar aneurysms in case of a poor vascular status with occlusion or lack of traditional endovascular access routes.

Neurovascular considerations in patients with Down syndrome and moyamoya syndrome.

In this article, we describe a rare and complex case of moyamoya syndrome in a 7-year-old boy with Down syndrome and atlantoaxial subluxation. The patient presented with an ischemic stroke in the left hemisphere and cervical cord compression with increased cord edema. Diagnostic digital subtraction angiography revealed unique patterns of vascular involvement, with retrograde flow through the anterior spinal artery, ascending cervical artery, occipital artery, and multiple leptomeningeal arteries compensating for bilateral vertebral artery occlusion.This case underscores the underreported phenomenon of upward retrograde flow through the anterior spinal artery in bilateral vertebral artery occlusion. We address the rare manifestation of posterior circulation involvement in moyamoya syndrome, highlighting the importance of considering atlantoaxial instability as a contributing factor, as the absence of atlantoaxial stability is a risk factor for vertebral artery dissection. This study contributes valuable insights into the intricate relationship of moyamoya syndrome, Down syndrome, and atlantoaxial instability, urging clinicians to consider multifaceted approaches in diagnosis and treatment. It also emphasizes the potential significance of the anterior spinal artery as a compensatory pathway in complex vascular scenarios.

“Worse than hell”: Complex Neuraxial Lesions Resulting in Tetraplegia and Blindness after Polytrauma - Case presentation

Background. Lesions of the vertebral artery (VA) may develop spontaneously or as a result of severe traumatic cervico-cephalic injuries. Most frequent VA injuries (VAI) result from blunt trauma to the spine or may be due to penetrating lesions. VAI plays a significant role in the broader context of cervical spine trauma by providing insights into the vascular aspects of spinal cord injury (SCI). Upper cervical spine fractures and accompanying subluxation, as well as transverse process fractures extending into the artery bone foramen, are associated with an elevated risk of VAI. Clinical case. A 63-year-old female patient with flaccid C4 AIS-A quadriplegia (global motor score 3/100), vertebral myelopathy, neurogenic bladder, sacral pressure sore, and blindness was transferred from the spinal neurosurgical department. The patient fell from the same level and suffered a mild brain concussion and, apparently, a minor cervical SCI on October 1, 2022. She was asymptomatic, then quickly became tetraplegic, and then blindness added on in a few days. She was operated on on October 7, 2022, for a C6 vertebral body fracture and a C5-6 dislocation. The surgical protocol consisted of anterior spinal cord decompression, dislocation reduction, and mixed anterior fusion with bone grafts and fixation screws. Following the traumatic event, a bilateral posterior cerebral artery (PCA) stroke subsequently produced blindness and partial optic atrophy in both eyes. Serial clinical and imaging examinations confirmed the diagnosis: a subacute bilateral occipital stroke and a chronic lacunar lesion in the right thalamus associated with a severe spinal cord lesion. Anticoagulation has partially improved the neurological outcomes of stroke in the PCA territory. Ethical considerations. The patient's next of kin has given written consent to the case study and to use the radiological images related to the case for academic purposes. The personal identity data was anonymized. The presentation of this clinical case has the approval of the ethics commission of TEHBA (no. 40205/01.09.2023). Discussion. The clinical example is notable for the concurrent development of two severely devastating neurological syndromes, quadriplegia, and blindness, which occurred after an initially minor cervical trauma and progressed gradually over a few days. VA lesions after cervical trauma are considered rare, and the diagnosis is difficult because the vast majority of individuals do not exhibit cerebral neurological symptoms (due to the collateral compensatory blood supply from the circle of Willis). Most of the patients with bilateral or dominant VA occlusions are symptomatic, with rapid (and possibly fatal) ischemic damage to the encephalon, cerebellum, or brainstem. The detection and tracking of evolutionary tendencies required a series of clinical tests, including fundoscopy, and imaging procedures, including native CT, MRI, and MR angiography scans of the brain and spine. Conclusions. Although VAI is a rare complication, in every polytrauma patient with head and neck trauma, VA damage should be suspected. Careful clinical and imaging monitoring through detailed serial imaging procedures must be performed for every person with severe cranio-cervical trauma. The clinical example emphasizes the importance of the interprofessional team's participation in the patient's care.

Abstract 123: First Off‐Label Use of the XIENCE Skypoint Stent for Mechanical Thrombectomy Rescue

Introduction Despite technical advances in mechanical thrombectomy (MT), failure to achieve recanalization in the posterior circulation remains a significant challenge. Rescue strategies to increase MT success in the posterior circulation have been explored. We demonstrate the first successful off‐label use of XIENCE Skypoint™ (Abbott), a balloon‐mounted drug‐eluting stent (DES), for intracranial MT rescue in the posterior circulation. Methods Case report and endovascular technique. Results A 52‐year‐old man with hypertension, hyperlipidemia, and deep venous thrombosis who presented with acute ischemic stroke in bilateral occipital, lateral pons, and cerebellar regions. Computed tomography angiography (CTA) showed bilateral vertebral artery occlusion consistent with a history of dissection in the setting of cervical manipulation. Admission National Institutes of Health Stroke Scale (NIHSS) 20. Last known well less than 12 hours from presentation. Intravenous thrombolysis was deferred as the patient was on pre‐admission anticoagulants. Mechanical thrombectomy failed after several unsuccessful passes (Fig 1). XIENCE Skypoint™ stent was deployed within the left vertebral artery (V4 segment) with restoration of flow preceded by eptifibatide drip (Fig 2). Repeat CTA at six months showed patent left vertebral and basilar arteries. Conclusion Rescue stenting using DES may be a successful and safe therapeutic intervention for challenging failed MT. The off‐label use of DES for intracranial pathologies continues to expand. This is the first case report in the literature describing successful rescue stenting using XIENCE Skypoint™ in the posterior circulation. Further investigation is warranted to fully elucidate the risks and benefits of this treatment approach.

Rescue Endovascular Treatment to Prevent Neurological Deterioration in Acute Symptomatic Bilateral Vertebral Artery Occlusion.

Bilateral vertebral artery occlusive disease has been considered as a favorable condition with good collaterals. However, the prognosis of acute ischemic stroke secondary to symptomatic bilateral vertebral artery occlusion (BVAO) and endovascular treatment (EVT) has rarely been reported. We retrospectively selected patients with acute ischemic stroke admitted for symptomatic BVAO between January 2020 and February 2023. All patients with ischemic stroke were evaluated for ischemic lesion and arterial status using brain imaging and angiography. The prognosis of acute stroke with symptomatic BVAO was compared between EVT and conventional treatment. Outcomes were evaluated using modified Rankin Scale (mRS) score at 3 months follow-up. Within the study period, 17 of 2,655 acute ischemic stroke patients were diagnosed with ischemic stroke with symptomatic BVAO. The median age of these patients was 70 (interquartile range 44-89) years, and 13 (76%) were male. Seven patients received emergent EVT with stenting and 10 patients received conventional medical treatment only. Nine of 10 patients with conventional treatment had in-hospital stroke progression and developed new ischemic lesions in the pons and midbrain. Five patients with fetal and hypoplastic posterior communicating artery presented bilateral cerebral peduncular lesions. At 3 months follow-up, 6 patients (35%) had favorable outcomes (mRS 0-2), of which 5 were treated with vertebral artery stenting and 1 received conventional treatment. Ischemic stroke in patients with acute symptomatic BVAO is uncommon. However, stroke progression is common, and the prognosis of most patients is poor. Rescue management such as EVT might be considered for symptomatic BVAO.

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.

Management of Cerebral 4-Vessel Disease With Anterior Circulation Symptoms by Stenting Both Vertebral Arteries at the Same Session.

Stroke is among the leading causes of mortality and morbidity worldwide. The coexistence of bilateral carotid and vertebral artery (VA) occlusion and/or stenosis is in the very rare entity group in the literature. Here, we present a case with bilateral carotid artery occlusion and bilateral VA stenosis, who presented with an atypical clinical presentation and underwent bilateral vertebral percutaneous transluminal angioplasty (PTA) and stenting in the same session. A 67 year old male patient was brought to the emergency department with complaints of inability to speak and weakness in both legs for 1 day. There were bilateral infarct areas in the anterior cerebral artery region and an additional infarct area in the left middle cerebral artery region. First, the right VA stenosis level was crossed using a 0.14 guidewire. After PTA, balloon-expandable stenting was performed with a 3.0×12 mm NC (non-compliant) balloon, and nearly complete recanalization was observed. Therefore, it was decided to perform an intervention on the left VA in the same session. As in this example case, in cases where cerebral perfusion is severely impaired, medical treatment after recanalization may be one of the best treatment options. The carotid arteries are the main arteries supplying the anterior circulation, and the vertebral arteries supply blood to the posterior circulation. However, in cases where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system. However, in cases such as this, where both carotid arteries are occluded/dysfunctional, all cerebral perfusion remains over the vertebrobasilar system and may be responsible for anterior circulation strokes. The situation becomes more severe if both vertebral artery critical stenosis is added. Synchronous carotid and vertebral artery revascularization is not recommended in the guidelines for patients with combined carotid and vertebral artery disease. In patients with four-vessel occlusion/stenosis, as in this particular case, the intervention method and priorities are unclear. We achieved a favorable clinical outcome with simultaneous bilateral vertebral artery angioplasty and stenting, a hazardous method that can be a guide as an approach option in similar cases.

Efficacy of endovascular therapy for basilar and vertebral artery occlusion: A systematic review and meta-analysis of randomized controlled trials

BackgroundThe best management for acute basilar artery occlusion (BAO) has increasingly been clarified by recent randomized controlled trials (RCTs). We conducted a systematic review and meta-analysis of RCTs comparing endovascular therapy (EVT) vs best medical management (BMM). MethodsWe searched PubMed, Embase, the CENTRAL, and ClinicalTrials.gov from January 1, 2000, to November 20, 2022. We included RCTs comparing EVT vs BMM in BAO or bilateral vertebral artery occlusion (VAO). Primary outcome was ambulation (modified Rankin Scale score [mRS] 0–3) at 90 days. Secondary outcomes were independence (mRS 0–2) at 90 days, death by 90 days, and symptomatic intracranial hemorrhage (sICH). Risk ratio (RR) with 95% CI was used as a measure of the association of EVT vs BMM with outcomes. ResultsFinal analyses included 4 RCTs with 988 patients with BAO or VAO. Pooled results showed that EVT vs BMM was associated with an increased rate of 90-day ambulation (RR 1.54, 95% CI 1.16–2.05), independence (RR 1.83, 1.08–3.08) and a reduced risk of mortality (RR 0.76, 0.65–0.89), but an increased risk of sICH (RR 7.48, 2.27–24.62) and the benefits might be confined to patients with BAO but not patients with VAO. EVT effect was modified by occlusion location with the basilar artery, with greatest benefit for proximal, intermediate benefit for middle, and least benefit for distal occlusions. ConclusionEVT compared with BMM might be associated with an increased rate of ambulation, independence and survival but with an increased risk of sICH in patients with acute BAO.

Reversal of Diffusion-Weighted Imaging Hyperintensities of the Pons after Endovascular Reperfusion for Proximal Extracranial Vertebral Artery Occlusion

Diffusion-weighted imaging (DWI) hyperintensities corresponding to ischemic areas have been regarded as an ischemic core. However, several studies have demonstrated the reversibility of DWI hyperintense signals in hyperacute stroke patients. We experienced the DWI reversibility of posterior circulation ischemia after revascularization of the proximal extracranial vertebral artery. The perfusion of the posterior circulation might be significantly reduced due to bilateral vertebral art ery occlusion. Considering this case, early improvement of the perfusion of the ischemic area might key role of DWI reversibility.

Abstract 1122‐000027: Bilateral Vertebral Artery Occlusion and Involvement of the Posterior Circulation

Introduction : Rationale: Bilateral vertebral artery occlusion with collateral reconstitution is a rare finding. Compared to patients with acute occlusion, symptom progression may be much slower [1]. Atherosclerotic risk factors lead to occlusion, including hypertension and hyperlipidemia, but it is unclear what leads to collateral reconstitution [2]. These patients may have collateral circulation from anterior and posterior circulation sources that are well developed [1] [2]. Sufficient collateral flow correlates with lower rates of hemorrhagic transformation following recanalization [3] [4]. However, given the risk of spontaneous hemorrhage from microvascular collaterals, the hemorrhagic risk associated with thrombolytic therapy in patients with moyamoya collaterals, due to the fragility of these vessels [5], must be balanced with the benefit of therapy in the presence of severe neurologic deficits along with the mortality and morbidity that may stem from the occlusion. Patient concerns: 67 year old Caucasian male with past medical history of coronary artery disease, abdominal aortic aneurysm, hypertension, history of tobacco use and type 2 diabetes mellitus presents with acute right‐sided weakness. Methods : Diagnoses: On admission, CTA Head and Neck suggested chronic total occlusion of bilateral V4 segments from their origin to the midportion with tandem bilateral high‐grade stenoses throughout the imaged distal V2 and V3 segments bilaterally. MRI could not be obtained because of old lumbar fusion spinal hardware. Cerebral angiography showed microvascular reconstitution, analogous to moyamoya, with slow mid basilar flow, which could be either due to occlusion or competitive flow from top of the basilar collaterals. Interventions: Patient received intra‐arterial integrilin and tPA thrombolysis with TICI 1 reperfusion. Results : Outcomes: Patient presented with NIHSS 18 notable for right sided weakness (2/5 strength in his right upper extremity and 1/5 strength in RLE), bilateral hemianopia, severe dysarthria and right gaze preference. Patient had significant improvement in his exam the next day following thrombolysis. Notably, patient had 5/5 strength in his right upper and right lower extremities compared to his strength on presentation. Repeat head CT on the following day after thrombolysis showed left pontine infarct. Repeat NIHSS was 3 at 24 hours for partial hemianopia, minor nasolabial flattening and mild dysarthria. Conclusions : Conclusion: Bilateral intracranial vertebral artery stenosis and occlusion commonly occurs distal to PICA and near the vertebrobasilar junction [2]. Proximal (specifically areas supplied by PICA) and distal territories within the posterior circulation are often infarcted [2], which can yield a unique exam upon presentation that can help accurately guide diagnosis and treatment when appropriately recognized. The involvement of collateral circulation can play a crucial role in patients undergoing endovascular revascularization therapy [6]. In the setting of bilateral vertebral occlusion with microvascular reconstitution, patients can still undergo catheter based thrombolysis, but not thrombectomy.

Modified Sternocleidomastoid Sparing Approach for Vertebral Artery (V1) to Common Carotid Artery Transposition: 2-Dimensional Operative Video.

Vertebral artery (VA) V1 segment to common carotid artery (CCA) transposition is an uncommon operation with existing literature describing dissection of the sternoclavicular head of the sternocleidomastoid (SCM) muscle.1,2 We present a modified approach for transposition without cutting the SCM. Our patient is a 76-yr-old female with history of a previous cerebellar stroke. Despite taking aspirin, she presented with another stroke resulting in severe dysarthria, vertigo, and gait disturbance. Magnetic resonance imaging (MRI) demonstrated several cerebellar infarcts. Catheter angiography demonstrated bilateral vertebral artery occlusion with filling from ascending cervical branches and a dominant left VA. We planned a left V1 to CCA transposition with a modified SCM-sparing approach for which the patient provided written informed consent. She was positioned supine with neck extended and face turned to the right. Neuromonitoring was utilized. A linear incision along the anterior border of the SCM was made, stopping 1.5 cm above the clavicular head. Neurovascular structures of the carotid sheath were dissected circumferentially and mobilized medially. The longus coli muscle over the C6 lateral mass was reflected medially. The vertebral artery was dissected to expose the maximum possible length. The inferior thyroid artery was sacrificed for better exposure. VA was ligated and transected. CCA was clamped. VA to CCA bypass was performed in a standard fashion. Surgical site was closed. The patient clinically did well postoperatively with immediate symptom improvement. Our video demonstrates an SCM-sparing technique of V1 to CCA transposition, which can be a less-extensive operation compared to the traditional approaches, which require transection of SCM head.

Letter to the Editor Regarding “Bilateral Vertebral Artery Occlusion After Cervical Spine Fracture Dislocation”

Letter to the Editor Regarding “Bilateral Vertebral Artery Occlusion After Cervical Spine Fracture Dislocation”

A Rare Case of Type II Odontoid Fracture With Bilateral Vertebral Arteries Occlusion Without Neurological Deficits

Cervical spine fractures are common fractures due to spine trauma. Odontoid fracture is responsible for 20% of cervical spine fractures. Vertebral artery injuries (VAIs) had widely focused in this setting due to its occurrence with upper cervical fractures. In our case of study, a 42-year-old female presented in the hospital’s emergency department with a history of cervical spine injury without neurological deficits. In further investigations, cervical spine X-ray, magnetic resonance imaging (MRI), and angiography were done to evaluate the possible injuries to the bone, spinal cord, and vascular structures surrounding the spine that eventuated in the accidental diagnosis of bilateral vertebral artery occlusion. This case of the study demonstrated the importance of diagnostic investigations that can evaluate in an emergency department and bilateral vertebral artery occlusion without neurological symptoms due to collateral arteries establishment.

Ruptured Spinal Aneurysms: Diagnosis and Management Paradigms

Spinal aneurysms (SA) are rare neurovascular pathologies with an unclear natural history and management strategy. We review the clinical and radiologic manifestations, management, and outcome of patients who presented with spinal subarachnoid hemorrhage (SAH) secondary to ruptured spinal aneurysms over a 10-year period. We provide a literature review about this condition and its management. All patients diagnosed with nontraumatic spinal SAH were collected from a single-center prospectively maintained database of patients with SAH between January 2010 and January 2020. Patients diagnosed with spinal aneurysms were reviewed. For each patient, demographic data, clinical presentation, imaging findings, management strategies, and outcomes are reviewed and discussed. Between January 2010 and January 2020, ten patients were diagnosed with nontraumatic spinal SAH (3 patients presented with isolated spinal SAH and 7 patients with concomitant spinal and posterior fossa SAH). Among those, 4 patients were found to have a spinal aneurysm as the cause of SAH. The aneurysms were located in the cervical regions in 3 patients (75%) and at the thoracic level in 1 patient. Two aneurysms (50%) involved the anterior spinal artery, and 2 aneurysms (50%) involved a radiculomedullary artery. One aneurysm was a flow-related aneurysm of the anterior spinal artery in the setting of bilateral vertebral artery occlusion and was treated by surgical clipping with good outcome. Three aneurysms were idiopathic pseudoaneurysms with a negative diagnostic evaluation for secondary causes. These pseudoaneurysms were treated conservatively; 2 patients did well and 1 patient passed away from severe intracranial vasospasm. Two aneurysms resolved on diagnostic angiogram, and 1 aneurysm was absent on initial angiogram and appeared on follow-up diagnostic imaging 3 months later. Spinal aneurysms are rare neurovascular pathologies that should be considered in the setting of spinal and/or posterior fossa subarachnoid hemorrhage. Conservative treatment may be a potential safe alternative to interventional treatment. Before the initiation of surgical or endovascular treatment, spinal angiography should be repeated because of the potential for spontaneous resolution.

A Case of Bilateral Hearing Loss.

Case PresentationA 53-year-old male presented to the emergency department with acute onset of bilateral hearing loss as well as vertigo and severe vomiting. The Head Impulse– Nystagmus–Test of Skew exam was indicative of a central neurologic process. Computed tomography angiogram of the head and neck revealed near-total bilateral vertebral artery occlusions in the second and third segments. The patient was admitted for further evaluation; subsequent magnetic resonance imaging revealed multiple areas of infarction in the cerebellar hemispheres, medulla, and occipital lobes.DiscussionThis case describes a unique presentation of a posterior stroke. Common symptoms include vertigo, loss of balance, and vomiting. However, bilateral hearing loss as a prominent symptom is uncommon. Imaging revealed a rare finding of bilateral vertebral artery occlusion.

Medial Medullary Infarction With Acute Bilateral Vertebral Artery Occlusions

Medial Medullary Infarction With Acute Bilateral Vertebral Artery Occlusions

Transverse-sigmoid sinus dural arteriovenous fistula presenting with recurrent transient ischaemic attack: A technical case report.

Intracranial dural arteriovenous fistulae (DAVF) are uncommon and account for approximately 1% of all strokes. All transverse-sigmoid sinus DAVFs require treatment because of the low rate of spontaneous regression and frequent association with aggressive neurologic symptoms. Endovascular embolization which aims for permanent obliteration of the lesion is now the primary treatment modality for all DAVFs. We present a 56-year-old patient with long standing history of intermittent TIA-like symptoms. Magnetic resonance (MR) angiography revealed right transverse-sigmoid sinus DAVF and bilateral vertebral arteries occlusion. The patient’s symptoms completely resolved upon successful trans-arterial embolization of the DAVF.

鈍的頸椎損傷に合併する椎骨動脈閉塞症例の検討(Vertebral artery occlusion associated with blunt traumatic cervical spine injury)

要旨【目的】鈍的頸椎損傷に合併する椎骨動脈損傷（以下VAI）は，時に重篤な脳梗塞を生じるが，確立された治療指針はない。我々は不安定型頸椎損傷に合併する椎骨動脈閉塞の症例を血管内治療の適応とし，整復固定術前に塞栓術を行ってきた。当院のVAI症例を検討し，椎骨動脈閉塞症例に対する塞栓術や長期予後について報告する。【対象】2015年1月～2018年4月に入院加療を行った全鈍的頸椎外傷症例を対象とした。頭頸部造影CT検査にてVAIの合併を認めた症例について，患者背景，頸椎損傷の形態，Denver grade，治療内容，脳梗塞合併の有無を後方視的に検討した。【結果】対象の鈍的頸椎外傷患者は89例で，15例（16.7%）にVAIを合併した。VAI患者の平均年齢は62.6歳で，半数が転倒転落を受傷機転とした。VAIの原因となった頸椎損傷は①亜脱臼，②環椎破裂骨折，③横突起骨折の3つであった。Denver grade IVの症例が最も多く12例であり，うち整復固定術を必要とした9例に血管内治療を行い，入院中および退院後のフォローにおいて明らかな脳梗塞を生じた症例は認めなかった。【結語】不安定性頸椎損傷に合併する椎骨動脈閉塞症例に対する整復固定術前の予防的塞栓術は，脳梗塞発症の予防に有効な治療手段となる可能性がある。

Occipital Artery to Extradural Vertebral Artery Bypass for Posterior Circulation Ischemia.

Posterior circulation ischemic strokes can have devastating consequences, despite medical therapies. Extracranial-intracranial bypass for the augmentation of flow is a treatment option for selected patients with hemodynamic compromise and recurrent ischemia. However, posterior circulation bypass carries a higher risk and lower patency rate than bypass with anterior circulation. To present the occipital artery to the extradural vertebral artery (OA-eVA) bypass for posterior circulation ischemia. We retrospectively reviewed our experience of the OA-eVA bypass surgery in the treatment of bilateral vertebral steno-occlusive disease. Seventeen patients were identified. Thirteen patients had bilateral vertebral artery (VA) occlusion (type I), while 4 patients had VA occlusion with contralateral VA severe stenosis (type II). All patients had cerebellar or pons infarction, for which the postoperative bypass patency rate was 100%, with carotid angiogram demonstrating excellent filling of the rostral basilar system or the posterior inferior cerebellar artery territory. The long-term follow-up outcome was favorable (modified Rankin score of 0-2) in 82% of patients (7 patients had complete resolution and 7 had improvement of symptoms) and unfavorable in 18%. One type II case without previous endovascular therapy developed recurrent ischemic onset associated with bypass occlusion. OA-eVA bypass is a minimally invasive and effective alternative to posterior circulation ischemia. It provides sufficient blood flow augmentation to the vertebrobasilar territory. The advantages of this novel therapeutic strategy include avoiding performing craniotomy and deep bypass and achieving shorter operative times compared to conventional bypass surgery.