Occlusion Of Left Vertebral Artery Research Articles

Isolated aneurysm of the proximal right subclavian artery treated with consideration toward cerebral circulation and vasculature

A 65-year-old man with an isolated aneurysm of the proximal right subclavian artery (SCA) (diameter, 50 mm) was successfully treated with a deliberate surgical strategy described here. Because of the occluded left vertebral artery (VA) and poor development of the circle of Willis, the distal portion of the right SCA was bypassed from the ascending aorta before resecting the aneurysm in order to maintain blood flow to the brain through the right VA. Consequently, the patient recovered without neurological complications. We conclude that conventional surgery remains effective for complex vascular diseases even in the era of advanced endovascular surgeries.

Acute cerebellar ischemia after lumbar spinal surgery: a rare clinical entity

To the Editor: We present a case of cerebellar ischemia following a lumbar spinal surgery with prolonged prone position. Acute cerebellar ischemia after lumbar surgery is extremely rare, and its exact cause is not well known [1, 2]. Compression of vertebral arteries as a result of the prone position and unusual neck rotation with prolonged surgery have been demonstrated as the causes of cerebellar hypoperfusion leading to ischemia [2, 3]. Our patient was an ASA physical status II, 69-year-old man with degenerative lumbar stenosis at L2–L3–L4 levels. The patient had small ischemic areas on his previous cranial magnetic resonance imaging (MRI), and a left vertebral artery occlusion was detected on his previous computed tomography (CT) angiography performed 2 years ago; with no neurological symptoms or signs relevant to those lesions. Clopidogrel and acetyl salicylic acid administered previously were discontinued 7 days before the operation to avoid the risk of intraoperative bleeding. Compression stockings were applied to the patient to prevent the thromboembolic events of both cardiovascular and central nervous system. The patient was turned into prone position with his head semiflexed and mildly turned to his right side on a donut cushion, not exceeding his normal range of motion. Neutral position could not be achieved because of his short neck. Parallel chest foams were placed because of lack of a spine frame. Total laminectomy and fusion by transpedicular screw stabilization was performed at L2 to L5 levels, and the duration of the operation was 6 h. Throughout the surgery, mean arterial pressure was kept at 65–70 mmHg levels for the majority of the operation. The patient had altering levels of consciousness, dysarthria, and dizziness 2 h after the surgery. Brain CT scan demonstrated an acute cerebellar ischemia with surrounding edema in both hemispheres, more marked on the left side (Fig. 1). The patient was discharged from the hospital 4 weeks later with satisfying recovery of consciousness and dizziness, although his dysarthria improved very slowly. The position of our patient might have compromised the blood flow of right vertebral artery. Also, our patient had a prior left vertebral arterial occlusion. Both the position and the prior left vertebral arterial occlusion might have contributed to the ischemia involving both sides of the cerebellum. Our preventive measures were the application of compression stockings and avoiding hypotension and extensive neck rotation. Additionally, a low molecular heparin prophylaxis could have been considered to prevent possible contribution of thromboembolic complication. Further, aspirin should have not been discontinued, as suggested in a most recent review [4]. We conclude that preference of neutral alignment of the neck, maintenance of mean arterial pressure in normal range, and F. Harman M. Yaman E. Kaptanoglu Department of Neurosurgery, Near East University Faculty of Medicine, Lefkosa, Mersin 10, Turkey

EComment. Extended sternal retraction and internal mammarian artery flow

We read with interest the manuscript by Espinoza et al. [1], in which the authors presented two patients in whom internal mammary artery (IMA) flow was compromised with extended sternal retraction during off-pump coronary artery bypass grafting (CABG). We would like to comment on the authors' paper with similar incidents that we have encountered in our practice. We had 3 patients in whom the left IMA flow was decreased when we widely opened the sternum retractor during CABG. The first patient had cerebrovascular disease (left vertebral artery occlusion and insignificant left internal carotid artery stenosis) in addition to coronary lesions. We detected an accessory ascending collateral branch from the IMA after careful exploration of the proximal part of the artery. Flow reduction was overcome with clipping of this vessel and freeing of the IMA. The procedure did not affect the neurological status of the patient in the postoperative period. In the second patient, the IMA divided into two branches after the middle segment, measuring 1 mm in diameter. Left anterior descending artery was bypassed with the suitable middle portion of the IMA. Sternal over-retraction caused flow reduction, which was overcome with the approximation of the sternal edges. In both patients, we proposed that the reason for the reduction in the flow of IMA was due to distention of the graft. In the third patient, there was no identifiable cause for the decrease in IMA flow, other than sternal retraction. Since IMA was the last anastomosed graft before the proximal anastomosis in our procedures, decrease in IMA flow was detected with simple palpation of the vessel and managed accordingly. IMA is still the gold standard graft for myocardial revascularization. We believe, it should be kept in mind that there may be various reasons which may lead to compromised IMA flow, either of the most common distention or sometimes of an idiopathic nature. Although flow compromise may be evaluated by transit-time flow measurement, simple palpation of the graft is also simple and effective method. Conflict of Interest: None declared

A case of traumatic intracranial vertebral artery injury presenting with life-threatening symptoms

Traumatic intracranial vertebral artery injury is a relatively rare but potentially fatal disease. We present a case of a 63-year-old man who presented with sudden onset of loss of consciousness after hitting his head. After immediate resuscitation, he showed quadriplegia and absence of spontaneous breathing. Brain and cervical spine magnetic resonance imaging revealed an atlantoaxial subluxation, fractured C2 odontoid process, left vertebral artery occlusion, and bilateral extensive ischemia in the medulla oblongata and high cervical spinal cord. Digital subtraction angiography demonstrated left vertebral artery dissection just below the level of vertebral body C2.

Doppler Ultrasonography and Computed Tomography Angiography Demonstrate Positional Occlusion of Vertebral Artery Associated With One-Sided Destruction of the Atlantoaxial Lateral Mass Caused by Rheumatoid Arthritis

Case report of a patient with rheumatoid arthritis (RA) and a positional occlusion of the left vertebral artery (VA). To describe the utility of Doppler ultrasonography and computed tomography (CT) angiography for the diagnosis of positional VA occlusion. In previous reports of positional VA occlusion in RA, angiography has been used for the diagnosis. However, it is difficult to demonstrate the three-dimensional relationship between the arteries and the bone structure with angiography. An 83-year-old man with a 20-year history of RA complained of severe vertigo when he leaned his head in the left-anterior direction. CT angiography in the neutral position revealed that the left VA was pinched between the posterior rim of the transverse foramen of C1 and the transverse process of C2. Doppler ultrasonography demonstrated positional VA occlusion and a severe reduction in blood flow at the position that most readily induces vertigo. Because the space between the transverse foramens of left C1 and C2 was reduced with the destruction of the left C1/C2 lateral masses, slight rotation, and anterior shift of C1 led to the occlusion of the VA. After posterior O-C2 fusion at the reduced position, the VA occlusion and vertigo disappeared. Doppler ultrasonography and CT angiography allow valuable measurements in the diagnosis of positional VA occlusion. The one-sided destruction of the C1/C2 lateral masses might be a causal factor for VA occlusion in RA. This is the first report of a new pathomechanism underlying positional VA occlusion demonstrated with three-dimensional CT angiography.

Cerebrovascular Events After Bevacizumab Treatment: An Early and Severe Complication

The indications for bevacizumab (a vascular endothelial growth factor inhibitor) have been expanded recently. Despite concerns for cerebrovascular events from bevacizumab treatment, detailed clinical and radiologic information are lacking. Using the Mayo Clinic Rochester database (January 2006-September 2010), we identified bevacizumab-treated patients who developed intracerebral hemorrhage, ischemic stroke or transient ischemic attack within 3weeks of bevacizumab treatment. Functional recovery was assessed using the modified Rankin scale 3months following the onset of cerebrovascular events. Ten consecutive patients (median age 58years, range 37-86) were included in this study. These patients received bevacizumab for a median duration of 3months (range 2-4months) for cancer treatment, and developed cerebrovascular events that comprised intratumoral hemorrhage (n=7), cerebral watershed infarction (n=1), transient ischemic attack (n=1), and left vertebral artery occlusion (n=1). Seven patients had chronic hypertension which was adequately controlled with a single anti-hypertensive agent. Significant increase in blood pressure was observed in nine patients during their acute presentation as compared with their baseline outpatient readings. Six patients died within 3months of these cerebrovascular events, and the remaining four patients had modest functional recovery. Cerebrovascular events are early and serious complications that should be considered in bevacizumab-treated patients who present with an acute neurologic deterioration.

A rare complication of a unilateral vertebral artery occlusion, which resulted in a basilar emboli after a C5–C6 bifacet dislocation in a professional rugby player: case study

Background Vertebral artery damage after cervical fracture and especially cervical dislocations is a recognized phenomenon. The incidence of significant intracranial neurology after unilateral vertebral damage is extremely rare, and to our knowledge, no such injury has been sustained while playing sport. Purpose To describe a rare vascular complication of a bifacet C5–C6 dislocation. Study Design Case report and clinical discussion. Methods We present a 28-year old white man who was a professional rugby player. He sustained a hyperflexion injury while playing scrum half in a recent league match, which resulted in a C5–C6 dislocation, diagnosed clinically and with a plain radiograph. The patient on admission had complete neurologic loss below C6. Results The patient underwent immediate computed tomography and magnetic resonance imaging (MRI) scans that revealed a 50% displacement of C5 on C6 with a complete unifacet dislocation and the other facet partially dislocated. The MRI revealed signal changes in the cord at the C5–C6 level and an intimal tear in the left vertebral artery. The decision was taken to reduce the dislocation when medically stable. A few hours after injury, after an episode of vomiting, the patient sustained a respiratory arrest owing to the embolization of a clot from the left vertebral artery into the basilar artery. Despite rapid embolectomy and subsequent permanent left vertebral artery occlusion, the patient sustained multiple infarcts in the cerebellar, thalamic, occipital, and pontine regions of the brain that eventually proved fatal. Conclusion This case shows a rare complication of unilateral vertebral artery occlusion. Despite early identification of a basilar infarct and a successful embolectomy, intracranial infarction occurred. Although there is no guideline for the treatment of vertebral artery damage, early reduction and anticoagulation may reduce the risk of cerebral infarction.

Traumatic Entrapment of the Vertebrobasilar Junction Due to a Longitudinal Clival Fracture: A Case Report

Vertebrobasilar junction entrapment due to a clivus fracture is a rare clinical observation. The present case report describes a 54-yr-old man who sustained a major craniofacial injury. The patient displayed a stuporous mental state (Glasgow Coma Scale [GCS]=8) and left hemiparesis (Grade 3). The initial computed tomography (CT) scan revealed a right subdural hemorrhage in the frontotemporal region, with a midline shift and longitudinal clival fracture. A decompressive craniectomy with removal of the hematoma was performed. Two days after surgery, a follow-up CT scan showed cerebellar and brain stem infarction, and a CT angiogram revealed occlusion of the left vertebral artery and entrapment of vertebrobasilar junction by the clival fracture. A decompressive suboccipital craniectomy was performed and the patient gradually recovered. This appears to be a rare case of traumatic vertebrobasilar junction entrapment due to a longitudinal clival fracture, including a cerebellar infarction caused by a left vertebral artery occlusion. A literature review is provided.

Percutaneous angioplasty and stenting of subclavian arteries before surgical coronary revascularization in a patient with an aberrant right subclavian artery

An aberrant right subclavian artery occurs in less than 2% of the population. An associated stenosis of the subclavian artery carries a risk of subclavian-coronary steal in patients who undergo coronary revascularization. We report on the case of a 54-year-old man admitted to our hospital for a coronary artery bypass graft (CABG). Angiographic examination revealed bilateral subclavian-artery stenosis with an aberrant right subclavian artery, anomalous origin of the right vertebral artery from the right common carotid artery, and left vertebral-artery occlusion. The patient underwent successful bilateral subclavian angioplasty and stenting.

Treatment of a giant vertebrobasilar artery aneurysm using stent grafts

This 65-year-old man presented to the authors' institution reporting neck swelling. Stage IIIA Hodgkin disease was diagnosed, and a computed tomography scan of the neck revealed a vertebrobasilar artery aneurysm. His medical history was significant for subarachnoid hemorrhage and coma 2 years earlier. Subsequent digital subtraction angiography demonstrated a giant fusiform vertebrobasilar junction aneurysm with associated basilar artery (BA) fenestration. Endovascular treatment of the giant aneurysm was performed by left vertebral artery (VA) occlusion and placement of two Jo-stent coronary stent grafts from the right VA to the BA. The postprocedure course was uneventful. Follow-up angiography performed 1 week postoperatively demonstrated complete exclusion of the aneurysm. This unique case is described and a review of the relevant literature is presented.

Posterior cervical spine arthrodesis with laminar screws: a report of two cases.

We performed fixation using laminar screws in 2 patients in whom lateral mass screws, pedicle screws or transarticular screws could not be inserted. One was a 56-year-old woman who had anterior atlantoaxial subluxation (AAS). When a guide wire was inserted using an imaging guide, the hole bled massively. We thought the re-insertion of a guide wire or screw would thus increase the risk of vascular injury, so we used laminar screws. The other case was an 18-year-old man who had a hangman fracture. Preoperative magnetic resonance angiography showed occlusion of the left vertebral artery. A laminar screw was inserted into the patent side (i.e., the right side of C2). Cervical pedicle screws are the most biomechanically stable screws. However, their use carries a high risk of neurovascular complications during screw insertion, because the cervical pedicle is small and is adjacent laterally to the vertebral artery, medially to the spinal cord, and vertically to the nerve roots. Lateral mass screws are also reported to involve a risk of neurovascular injuries. The laminar screw method was thus thought to be useful, since arterial injuries could thus be avoided and it could also be used as a salvage modality for the previous misinsertion.

Recurrent cerebral embolism in a young adult with Down?s syndrome

Sirs: Patients with Down’s syndrome, the most common human chromosomal malformation, often suffer from a variety of concomitant disorders, such as congenital heart disease, leukemia, or malignancy [5]. Several cases of Down’s syndrome (DS) with stroke disorders and moyamoya-like vessels have been reported in the literature [2, 3, 10, 11]. We report here a case of recurrent embolic stroke in a young adult with DS. A 31-year-old right-handed female with DS developed a sudden onset of nuchal pain and vertigo. She could not stand because of weakness in her lower extremities. She was admitted to Osaka Medical College on September 6, 2003. A karyotype of trisomy 21 had been confirmed when the patient was 1 month old. Upon her admission now, the stigmata of DS were present: ocular hypertelorism; broad, flat facies; wide neck; low-set, posteriorly rotated ears; and short hands with clinodactylism. The rest of the physical examination, including her cardiovascular system, was unremarkable. She had entered into a confused state and her speech had become slow and slurred. A neurological examination showed hemiparesis with hyperreflexia and Babinski’s sign on the right side. Both eyes rested in an inward position, and there was paralysis of upward and downward gaze. Striking dysmetria was noted in the left upper and lower extremities. Her gait was very broad-based and she could not walk without support. Cranial MRI showed hypersignal intensity in the left cerebellar hemisphere on T2 and diffusionweighted images, and in the medial part of the left thalamus on diffusion-weighted images (Fig. 1a, b). MR angiography of the brain was normal. There were normal findings in several studies: complete blood count, sedimentation rate, prothrombin time, partial thromboplastin time, thrombin anti-thrombin III complex, fibrinogen, fasting plasma glucose, serum cholesterol, triglyceride, C-reactive protein, antinuclear antibody, rheumatoid factors, serology of syphilis, antiphospholipid antibodies, protein C, and urine homocystine levels. There were normal results in a cardiac evaluation that included electrocardiogram, echocardiogram, and 24-hour rhythm monitor. A spine roentgenogram revealed a dislocation of the C1 and C2 vertebrae (Fig. 2a). Color-coded Doppler ultrasonography showed anterograde and severely reduced flow in the left vertebral artery. She was treated with aspirin. On 13th day after admission, she suddenly developed memory disturbance. Neurologically, her hemiparesis and motor ataxia were not aggravated, and there was no evidence of other abnormalities. A follow-up MRI of the brain showed high signals in the pons as well as in the bilateral hippocampal and occipital regions on T2 and diffusion-weighted images (Fig. 1c, d). Three-dimensional helical CT (3D-CT) demonstrated hypoplasia of the left vertebral artery and local occlusion at the C2 level; this was the same portion where there was the atlantoaxial dislocation (Fig. 2b). After a relapse of the disease, she was treated with aspirin and ticlopidine hydrochloride. Her neurological signs, except for amnesia, then improved. The occurrence of stroke in DS has been rarely reported; and some of the cases that have been reported were secondary to cyanotic heart disease with paradoxical emboli or to meningitis [11]. Epidemiologic studies have found a higher incidence of moyamoya syndrome in patients with DS [6]. Patients with DS associated with cerebral amyloid angiopathy have been represented in few previous reports [4]. Our patient manifested a top-ofthe-basilar-artery syndrome without evidence of any congenital cardiac lesion, right-to-left shunts, or valvular endocarditis. These emboli usually present as cerebral infarcts in the carotid distribution. Moreover, there were no stenosed or occluded lesions of major arteries on cranial MR angiography. The findings of 3D-CT and Doppler ultrasonography suggested that posterior circulation stroke in our patient might result from kinking and occlusion of the vertebral artery at the level of an atlantoaxial dislocation. To our knowledge, there have been no previous reports of patients with DS associated with infarction caused by atlantoaxial dislocation. Stroke due to atlantoaxial dislocation has been observed in a few cases, most of which were caused by cervical spine trauma [8, 9] and rarely by ankylosing spondylitis [14] or cranio-cervical anomalies [1]. In a retrospective review of cineangiography of patients with DS, 40 % of LETTER TO THE EDITORS

Accident vasculaire cérébral ischémique par dissection artérielle vertébrale

Strokes due to vertebral artery lesions are not yet well known in children. We report on a case of post-traumatic vertebral artery dissection responsible for ischemic stroke in a 8-year old boy. Headache, vomiting and a brief loss of consciousness were the main initial signs. Neurological examination showed a locked-in syndrome. Cerebral imaging revealed lesions in cortical cerebellar hemisphere, cerebral pedoncular and protuberance. An arteriogram performed on day 10 showed left vertebral artery occlusion at C2 levels consistent with vertebral dissection. Antiagregants treatment was given. Neurological recovery was good. Pertinent clinical data of 24 children who had strokes due to a vertebral artery dissection are analysed. Vertebral artery dissection is presently a well-known cause of childhood strokes. Benefits from anticoagulants are now established.

Bilateral Vertebral Artery Lesion After Dislocating Cervical Spine Trauma

This case report illustrates the problems associated with diagnosis and management of vertebral artery injuries resulting from dislocating cervical spine trauma. Treatment involved the principles of anterior stabilization of dislocating cervical spine fracture as well as the diagnostic procedures and therapeutic modalities appropriate for vertebral artery lesions. Because vertebral artery injuries with cervical spine trauma are rarely symptomatic, they can easily be overlooked. Bilateral or dominant vertebral artery occlusion, however, may cause fatal ischemic damage to the brain stem and cerebellum. Cervical spine dislocation was stabilized immediately after admission using internal fixation by ventral plate and corticocancellous bone graft. Immediate angiography was performed when brain stem neurologic dysfunction manifested 36 hours after surgery. The patient was treated with anticoagulation, osmotherapy, and controlled hypertension. A fatal outcome resulted in this case of dominant left vertebral artery occlusion. Necropsy even revealed bilateral vertebral artery damage at the level of the osseous lesion. The possibility of the complication of a vertebral artery lesion should be kept in mind when examining patients with cervical spine trauma, especially in patients with fracture-dislocation. Immediate identification by vertebral angiography, magnetic resonance imaging, or thin-slice computed tomography scan is necessary for optimal management of this injury.

Concurrent Monitoring of Brainstem Auditory and Somatosensory Evoked Potentials During Carotid Endarterectomy

Intraoperative management of a 68-year-old man with a 3-month history of presyncopal attacks presenting for left carotid endarterectomy is reported. Preoperative angiograms revealed that the patient had a 90% stenosis of his left internal carotid artery and a 35% stenosis of right internal carotid artery, absent posterior communicating arteries, a totally occluded left vertebral artery, and a right vertebral artery that became compressed upon turning his head to the right, often precipitating the presyncopal attacks. The surgical procedure was managed with intraoperative monitoring of both brainstem auditory and somatosensory evoked potentials. The patient had an uneventful outcome. The anesthetic management is discussed.

Vertebrobasilar occlusive disease in children. A recognizable clinical entity.

A 10-year-old boy experienced many brief episodes of neurological dysfunction over an eight-month period culminating in a major deficit for which he was hospitalized. Transient features included diplopia, sense of dizziness, confusion, and language disturbances. Admission followed onset of a right sensorimotor disturbance associated with a right appendicular ataxia and anisocorla. Angiography demonstrated a total occlusion of left vertebral artery at two sites and segmental narrowing of the right vertebral artery at the level of the second cervical vertebra, with attenuated flow of dye in the left posterior cerebral artery. Clinical and radiographic findings suggested repeated ischemic insults to the left thalamic area and upper mid-brain, possibly from recurrent microembolization, and two of the six other reported cases of vertebrobasilar occlusive disease in children share similar findings suggesting a recognizable neurological entity.