Symptoms Of Vertebrobasilar Insufficiency Research Articles

Abstract 286: Endovascular Management of Pediatric Vertebro‐Vertebral Arterio‐Venous Fistula: Case report

Introduction Vertebro‐vertebral arteriovenous fistula (VV‐AVF) is a rare vascular malformation with abnormal high flow shunt between extracranial vertebral artery and an adjacent vertebral vein plexus without intervening capillaries.1 While seen in both adult and pediatric populations, the majority of the VV‐AVFs seen in childhood are largely congenital, seen in the setting of connective tissue diseases such as Ehler‐Danlos Syndrome, Neurofibromatosis type 1, and Marfan’s syndrome, with abnormal involution of the proatlantal system also thought to be implicated.2,3,4 Approximately 70% of the presenting population are symptomatic at presentation, with a pulsatile mass over the side of the neck or pulsatile tinnitus. Additionally, symptoms of vertebrobasilar insufficiency including gait abnormalities, limb weakness, vertigo, recurrent vomiting, diplopia, and in severe cases, cardiac decompensation can also be seen.5 Methods This is a case report of a 2‐year‐old boy presented to our pediatric neurovascular center of excellence with a progressively enlarging pulsatile left neck mass appreciated a year ago. Further evaluation with neck MRA followed by catheter cerebral angiogram revealed an upper cervical AVF with primary arterial feeders from V3 segment of the left vertebral artery, enlarged left occipital artery, and retrograde filling via the right vertebral artery into the left V4 with a direct shunt into a large venous pouch which drained into the vertebral venous plexus. Results Given the progressive enlargement of the mass, location of AVF, and concern for detrimental subsequent venous congestion, decision was made to pursue elective endovascular embolization of the VV‐AVF. The goal was set to obtain complete occlusion of the venous pouch to obliterate all arterial inflow contribution and prevent further recruitment. Occipital artery catheterization was attempted however given the redundant anatomical loops; optimum microcatheter navigation was not feasible. Given the non‐dominant configuration of the left VA, along with the presence of left AICA‐PICA system off the basilar trunk, coil embolization of the venous pouch followed by sacrifice of the V3 segment left VA was achieved satisfactorily leading to obliteration of the AVF along with all the arterial contributions from bilateral vertebral arteries and left occipital artery (Figure‐1). Given the potential vertebrobasilar inadvertent embolization, the procedure was performed under continuous neurophysiological monitoring and post‐periprocedural therapeutic anticoagulation. The patient tolerated the procedure well without any intraoperative issues. He was monitored in the pediatric ICU for 24 hours after the procedure, and subsequently discharged home. Conclusion We report a successful endovascular coil embolization of a VV‐AVF. To our knowledge, this is the youngest reported case where endovascular technique was successfully utilized to achieve cure of such high flow VV‐AVF in this 2‐year‐old patient. Systematic and methodical angiographic analyses with close post‐procedural monitoring are pivotal in ensuring successful outcomes.

Abstract Number ‐ 76: Bow hunter’s syndrome‐ a rare case of hearing loss associated with co‐dominant vertebral artery compression

Introduction Bow hunter’s syndrome (BHS), also known as rotational vertebral artery syndrome, refers to symptomatic vertebrobasilar insufficiency (VBI) caused by mechanical compression and severe stenosis or occlusion of the vertebral artery (VA) during neck and head rotation. Etiologies include bony spurs and osteophytes, or hypertrophic muscles and ligaments compressing typically on the dominant vertebral artery. Upon turning their head, patients experience posterior circulation symptoms such as vertigo, dizziness, syncope, nausea, tinnitus, or headache. These patients are at risk of stroke due to repetitive mechanical damage to the vessel and thromboembolism. [1] We present a rare case of BHS associated with hearing loss that was caused by bony spurs compressing on a left co‐dominant vertebral artery seen on turning head to both sides. Methods A woman in her 50s presented with sporadic progressive episodes of dizziness which started about 4 years. In addition, she reported experiencing episodic tinnitus in her left ear, frequent headaches, neck pain, and syncopal episodes. She was diagnosed with severe left ear sensorineural hearing loss (SNHL). Vestibular therapy and multiple neuropathic medications (nortriptyline, gabapentin) only provided her with minimal relief. Results Examination showed left SNHL and neck tenderness. X‐ray of cervical spine showed bony hypertrophy adjacent to the dens and inferior to the anterior arch of C1, suggestive of large osteoarthritic bony spurs. CT angiogram showed narrowing of the left vertebral artery at C1 due to severe hypertrophic arthropathy of the lateral mass articulation. It also showed impingement of the left VA in the left transverse foramen. The intradural portion of the VA (V4) appeared to be co‐dominant with normal size. Dynamic cerebral angiogram revealed near occlusion of the left VA at the level of C1‐C2 with head to the right. Left VA remained patent in neutral position, and experienced reduction in flow with head rotation to the left. The dynamic stenosis of VA caused by mechanical compression upon head turn leading to VBI, and reversal of stenosis when rotating head to neutral position was consistent with diagnosis of Bow hunters syndrome. Conclusions This case report highlights a rare presentation of VBI caused by dynamic stenosis of VA as a sequela of mechanical compression of a co‐dominant VA upon head turn to both sides. Only about 2% of the BHS patients experience symptoms during head turn to both sides [2], which was the finding in our patient. Furthermore, this case illustrates an association between BHS and SNHL. Hearing loss is previously described in vertebral artery atresia [3]; however, we present a novel association between acquired BHS and SNHL. Although we could not prove the causality, the coexistence of the two conditions in this patient may help to elicit further clinical consideration and evaluation in patients with SNHL of unknown etiology.

Morphometric evaluation of cerebellar lobules in individuals with unilateral vertebral artery hypoplasia.

Vertebral arteries (VAs) provide blood circulation to the posterior fossa in general and are the main blood supply of the posterior fossa structures of the brain. Our aim in this study is to analyze the segmental volumetric values of cerebellar structures with the voxel-based volumetric analysis system in individuals with unilateral vertebral artery hypoplasia. In this retrospective study, segmental volumetric values/percentile ratios of cerebellar lobules were calculated using 3D fast spoiled gradient recall acquisition in steady-state (3D T1 FSPGR) MRI sequence images of the brain in individuals with unilateral vertebral artery hypoplasia (VAH) and in those without bilateral VAH and any symptoms of vertebrobasilar insufficiency as the control group was evaluated in volBrain ( http://volbrain.upv.es/ ). The VAH group consisted of 50 (19 males/31 females) and the control group had 50 (21 males/29 females) individuals. The cerebellar lobule III, IV, VIIIA and X total volumes and the cerebellar lobule I-II, III, IV, VIIIA and X gray matter volumes were lower in the hypoplastic side than the non-hypoplastic cases and also than the contralateral side of the hypoplastic cases in the VAH group. In addition, it was found that that lobules IV and V had lower cortical thickness and lobules I-II had a higher coverage rate in the intracranial cavity in the hypoplastic side than the non-hypoplastic cases and also than the contralateral side of the hypoplastic cases (p < 0.05). In this study, it was found that cerebellar lobule III, IV, VIIIA, X total volumes and cerebellar lobule I-II, III, IV, VIIIA, X gray matter volumes in addition to lobule IV, V cortical thicknesses were low in individuals with unilateral VAH. Being aware of these variations and taking them into account during future volumetric studies on the cerebellum are very important.

Kimmerle anomaly as a cause of extravasal compression of the vertebral artery

Kimmerle anomaly, also known as ponticulus posticus, is a commonly known variant of the atlas anatomy. It occurs as a result of complete or incomplete ossification of the posterior atlanto-occipital membrane over the groove of the vertebral artery, which leads to the formation of an arcuate foramina containing the vertebral artery and the posterior branch of the C1 spinal nerve. This anatomical variation is associated with symptoms of vertebrobasilar insufficiency, various types of headache, visual impairment, photopsia, syncope, drowsiness, reduced work capacity, unsteady gait, sleep disturbance, panic attacks.Objective of the article is to highlight the attention of physicians on the widespread and not well understood Kimmerle anomaly, which is the cause of ischemic disorders in the vertebrobasilar circulation due to extravasal compression of the vertebral arteries.In the case of signs of impaired blood flow in the vertebrobasilar circulation, an X-ray of the cervical spine has to be done. In case of Kimmerle anomaly, ultrasound of neck vessels and transcranial doppler with functional tests should be performed. In the case of significant influence of disorder on the vertebrobasilar circulation, computed tomography with angiography is mandatory. If the patient's large vertebral artery is compressed, indications for surgical decompression of the vertebral artery at the level of the atlas is indicated. In cases of mild symptoms of cerebral vertebrobasilar circulation, symptomatic medication, wearing a Chance collar, physical therapy, and regimen restrictions are prescribed.

Signs and symptoms of vertebrobasilar insufficiency: A systematic review

Signs and symptoms of vertebrobasilar insufficiency: A systematic review

Total autogenous revascularization of an innominate artery occlusive disease

Total autogenous revascularization of an innominate artery occlusive disease

An interesting case of dizziness: Bow Hunter's syndrome due to Kimmerle anomaly diagnosed with provocative DSA

BACKGROUND: Rotational occlusion of the vertebral artery known as Bow hunter's syndrome(BHS) is a very rare cause for transient vertebrobasilar insufficiency symptoms. Complete or incomplete ossification of the posterior atlantooccipital membrane is called a Kimmerle anomaly which causes symptom in only 5.5% of patients with this anomaly. Early diagnosis with high index of clinical suspicion and provactive digital substraction angiography aids in prompt surgical repair, relieving the patient from the disabling symptoms and avoiding unnecessary ineffective symptomatic therapies.

Stenting of the first segment of the spinal artery in the acutest period of ischemic stroke in the vertebrobasilar territory

To analyze hospital and long-term results of stenting of the V1 segment of the vertebral artery (VA) in the first hours after acute cerebral hemopoiesis/transient ischemic attack (stroke/TIA) in the vertebrobasilar territory (VT). The current retrospective study from 2012 to 2019 included 169 patients with hemodynamically significant stenosis of the V1 segment of the VA, who underwent emergency stenting in the first hours after the onset of stroke. The mean time between the development of stroke and correction was 368.5±129.8 minutes. The average time between admission to the medical institution and submission to the X-ray operating room was 89.2±10.7 minutes. VA stenting was performed through the transfemoral approach. In 118 cases (69.8%) a drug eluting stent was implanted, in 51 (30.2%) a bare metal stent was implanted. 90% of VA segment V1 stenosis was diagnosed in 48 patients before the onset of stroke. Of these, 33 received conservative therapy for vertebrobasilar insufficiency (VBI) for 2.5±1.0 months in anticipation of regression of the disease. The remaining 15 did not have VBI symptoms and did not need active drug treatment. Ultimately, within this sample, the time interval between the visualization of stenosis and the onset of stroke was 3.0±1.0 months. In 17 patients, stroke/TIA in VT became recurrent. The period between two neurological events was 1.5±0.5 months. Nine patients did not wait for the planned intervention due to the development of an adverse neurological event before the appointed date of hospitalization. The other 8 did not appear for the interventional correction on time due to subjective reasons and were again admitted to the medical facility on an urgent basis. During the hospital follow-up period, no adverse cardiovascular events were recorded. When assessing the dynamics in the neurological status, there was a significant regression of the deficit by the time of discharge from the hospital. In the long-term follow-up period (38.2±20.4 months), a fatal outcome was recorded in 2.4% of cases (n=4). Non-fatal myocardial infaction was diagnosed in 5 patients (2.9%). Restenosis of the stent in the VA was visualized in 56 patients (33.1%). In 17 cases, it became symptomatic (10.0%). All patients underwent repeated stenting with a successful result of the procedure. Emergency stenting of hemodynamically significant stenosis of the V1 segment of the VA in the acute period of stroke in VT is a safe and effective method of revascularization characterized by the absence of adverse cardiovascular events at the hospital stage of observation.

Endovascular Treatment of the Vertebral Artery Origin Stenosis by Using the Closed-Cell, Self-Expandable Carotid Wallstent

Retrospective, single-center study between December 2006 and November 2018. There were 72 symptomatic patients refractory to medical management who were treated with a closed-cell, self-expandable carotid Wallstent (Boston Scientific, Marlborough, Mass) of the origin of the vertebral artery. Overall technical success was 100%. Procedure-related complications occurred in 11% (eight) of patients: acute stent thrombosis (three), minor stroke (three), sudden asystole (one), and stent shortening (one). There were no permanent neurologic complications. In-stent stenosis (one) or stent shortening (two) occurred in 6% (3/49) of patients at a mean follow-up of 1 year. Recurrent symptoms of vertebrobasilar insufficiency occurred in 5% (3/57) of patients. Endovascular treatment of symptomatic stenosis at the origin of the vertebral artery using the closed-cell, self-expandable carotid Wallstent is technically feasible and effective in alleviating patient symptoms.

Yes, we should abandon pre-treatment positional testing of the cervical spine

Although there seems to be no causality between cervical spine (CS) manipulation and major adverse events (MAE), it remains important that manual therapists try to prevent every potential MAE. Although the validity of positional testing for vertebrobasilar insufficiency (VBI) has been questioned, recently, the use of these tests was recommended. However, based on the low sensitivity of the VBI tests, which may result in too many false-negative results, the VBI tests seem to be less valuable in pre-manipulative screening. Moreover, because the VBI tests are unable to consistently produce a decreased blood flow in the contralateral vertebral artery in (healthy people), the underlying mechanism of the test may not be a valid construct. There are numerous cases reporting MAE after a negative VBI test, indicating that the VBI tests do not have a role in assessing the risk of serious neurovascular pathology, such as cervical arterial dissection, the most frequently described MAE after CS manipulation. Symptoms of VBI can be identified in the patient interview and should be considered as red flags or warning signs and require further medical investigation. VBI tests are not able to predict MAE and seem not to have any added value to the patient interview with regard to detecting VBI or another vascular pathology. Furthermore, a negative VBI test can be wrongly interpreted as ‘safe to manipulate’. Therefore, the use of VBI tests cannot be recommended and should be abandoned.

Endovascular Treatment of Chronic Total Occlusion in the Subclavian Artery: A Review of 23 Cases.

Objectives and Background: To review technical details and long-term outcomes of endovascular treatment of chronic total occlusion (CTO) of the subclavian artery.Methods: From January 2010 to May 2017, 23 patients (17 male; median age, 65 years) underwent endovascular treatment for CTO of the subclavian artery. All lesions had been diagnosed by duplex scanning or computed tomography angiography before treatment. Sixteen (70.0%) patients had symptoms of vertebrobasilar insufficiency, 6 (26.1%) patients had symptoms of arm ischemia, and 2 (8.7%) patients were asymptomatic. Duplex scanning revealed that 16 patients had grade 3 and 7 patients had grade 2 steal blood flow. After recanalization, lesions were treated by stenting. Patients were followed up at 1, 3, 6, and 12 months after endovascular treatment, and annually thereafter.Results: The overall technical success rate was 91.3% (21/23). The successful recanalization rate of antegrade and retrograde approaches were 68.2% (15/22) and 75.0% (6/8), respectively. The rate of clinical symptom remission was 95.2% (20/21) after treatment. No perioperative death or permanent neurological deficits were observed. One patient had arterial dissection treated by covered stent. The estimate cumulative primary and secondary patency rates at 5 years were 74.6 and 78.8%, respectively.Conclusion: Endovascular treatment is a feasible and safe treatment for CTO lesions of the subclavian artery.

Changes in Vertebral Arterial Blood Flow During Premanipulative Tests in Participants With Upper Cervical Spine Motion Restriction

ObjectiveThe purpose of the present study was to measure changes in blood flow velocity and volume flow rate (VFR) in the contralateral vertebral artery (VA) during end-range rotation and pre-manipulative hold at C1-C2 and to compare these measurements between participants with and without C1-C2 range of motion (ROM) restriction. MethodsThis research was approached as an exploratory study and designed as a parallel noninterventional controlled trial with intentionally equal allocation, for studying diagnostic tests. Fifteen women and 13 men (mean age 44) were recruited (volunteer sample) in physiotherapy clinics. No participant had any current neurologic or vertebrobasilar insufficiency symptoms. The measurements of 13 participants with a limited ROM C1-C2 and 15 with no limitation were compared. Blood flow velocity and VFR in the contralateral VA were measured using color duplex Doppler imaging in 3 neck positions: neutral, maximal rotation, and pre-manipulative hold of C1-C2. ResultsPre-manipulative hold significantly (P < .01) decreased all blood flow velocity parameters and VFR, mainly in the left VA. End-range rotation showed a significant (P < .05) decrease in the peak systolic velocity in the left VA. No significant differences were found between participants grouped by the presence or absence of a C1-C2 ROM restriction. ConclusionA C1-C2 rotational ROM restriction does not appear associated with change in a significantly reduced VA blood flow due to the neck position.

Clinical neurological and neuro-orthopedic characteristics of patients with vertebral artery syndrome of extravasal genesis

The article presents the results of clinical neurological and neuro-orthopedic examination of 48 patients with symptoms of vertebrobasilar insufficiency associated with complications of osteochondrosis. The main clinical syndromes that were observed in this group of patients were highlighted, the general characteristics of cardiovascular pathology, changes in brain during MRI examination and the severity of arterial sclerotic disease during ultrasound examination of the main arteries of the head and neck was given. On the basis of neuro-orthopedic examination of the cervical spine, specifically during examination of the active and passive range of movements, functional disorders in the form of restriction of movements were defined. By means of palpation, provocative and specific tests for certain motor segments, the main etiopathogenetic mechanisms of these disorders were identified. The program of clinical treatment was based on medical history, assessment of factors in the diagnosis of heart disease, analysis of cerebral blood circulation disorders in anamnesis, as well as provocative factors, which were overwhelmed by development. Surrounding the neuro-orthopedic examination of the neuro-orthopedic examination. The withers, they swallowed respect for a volume of rugs in the sheer ridge, conducted the Glison test, provocative tests on movements segments, palpation and percussion. The main types of postural disorders in patients with vertebral artery syndrome of extravasal origin have been investigated. As a result of clinical and neuro-orthopedic comparison, a higher frequency of Barre-Lieou syndromes, vestibulo-ataxic and vestibulo-cochlear disorders in patients with round posture was found, while the syndrome of ophthalmic disorders was observed with equal frequency in patients with round (70,8%) and round-incurvate (74,0%) posture and significantly more often compared to the group of patients with normal posture (49,9%). Vestibulo-ataxic syndrome was significantly more frequent at suspicion on facet syndrome or uncovertebral arthrosis (58,8%) in comparison with the group of patients with suspicion on protrusion / herniated intervertebral disc (11,8%).

Long Term – Twenty Nine Years – Results of the Conventional Surgical Treatment of the Subclavian Steal Syndrome – A Single Center Experience

Introduction: The aim of the study was to assess the patency rates, symptoms resolution rates and the safety of the surgical procedures performed in the conventional surgical treatment of the subclavian steal syndrome, which is caused by severe atherosclerotic lesions of the proximal part of the subclavian or innominate artery and may result in cerebral or upper extremity ischemia. Vast majority of those lesions may be treated with endovascular methods. However, in particular cases conventional surgical procedure remains the best option. Methods: A retrospective review of 75 patients with subclavian steal syndrome, who underwent conventional surgical treatment in our Department between 1988 and 2019, was performed. The vertebrobasilar insufficiency symptoms that covered: dizziness, vertigo, headache, tinnitus, drop attacks, perioral numbness, visual disturbances and arm claudication were most commonly presented among our study group. The indications for surgical treatment included: 44 subclavian artery occlusions, 18 failed angioplasty procedures, 7 innominate artery stenosis, 3 innominate artery occlusions, one carotid subclavian graft thrombosis and 2 restenoses after multiple transluminal angioplasties with stent implantation. The following vascular procedures were performed: 38 subclavian-carotid transpositions, 16 carotid-subclavian PTFE bypasses, 16 endarterectomies of the subclavian or innominate artery, 4 aorto-subclavian or aorto-innominate artery bypasses and one carotid-subclavian side-to-side anastomosis. During long-term follow-up period each patient underwent clinical examination, blood pressure ratio measurement between upper extremities, ultrasound examination and spiral Computed Tomography angiography at regular intervals. The life table method was used to calculate patency rate, overall survival rate, and symptom-free survival. Results: 30 day primary patency and symptom-free survival were observed in 69 patients (92%). Early thrombosis of subclavian artery with concomitant stroke complicated 3 operations (4%), temporary left phrenic nerve disfunction was observed in 5 cases (6,7%) and lymph leak occurred in 6 patients (8%). In one patient with Marfan syndrome a post-operative dissection of the transposed subclavian artery with the vessel obstruction was observed - despite this partial resolution of symptoms was achieved (1,3%). One patient died due to stroke after transposition complication treatment (1,3%). 49 out of the 75 patients (65,3%) of study group remained under direct supervision during the follow-up period ranging from 1 to over 19 years (12-228 months). 7 stenoses of the subclavian artery (14,3%), one subclavian artery occlusion (2%), one false aneurysm of innominate artery (2%), 6 vertebral artery occlusions (12,2%) and one subclavian dissection were stated (2%). Despite those findings 41 patients (83,6%) remained asymptomatic during the whole follow-up period. Conclusion: 1. Surgical treatment of the subclavian steal syndrome is featured with low mortality rate and relatively small number of complications. 2. Long term patency rate exceeding 80 % combined with good symptom-free survival confirms the efficacy of conventional surgical treatment. 3. Open surgery should be the treatment of choice in case of severe in-stent restenosis or occlusion after endovascular procedures. Disclosure: Nothing to disclose

Сlinical and instrumental evaluation of vertebral arteries stenting efficiency in the short-term and long-term postoperative periods

Objective: to evaluate the effectiveness of transluminal angioplasty with stenting in the treatment of atherosclerotic stenosis of the vertebral arteries (VA) proximal segment. Materials and methods. One hundred twenty-seven patients (97 men and 30 women, mean age 60 years) with symptomatic (72% of patients) and asymptomatic (28% of patients) stenosis of the VA were examined, the degree of stenosis according to X-ray angiography was 76±11%. One hundred fifteen (91%) patients with 127 (91%) implanted stents were surveyed over time (average follow-up time 13 months). Results. Technical success was achieved in 94% of cases. In the perioperative period, no acute cerebrovascular events, myocardial infarctions or deaths were registered. Recurrence of symptoms of vertebrobasilar insufficiency was noted in 14% initially symptomatic patients. According to ultrasound study data, restenosis ≥50% or reocclusion of the VA stent was detected in 40% cases. Damage to the integrity of the stent was diagnosed in 8% cases, which in all observations was combined with restenosis. Repeated derangement of stent patency after restenting of 11 VA in the period of 4–6 months was revealed in 60% of cases (2 reocclusions and 4 restenoses). Conclusion. Angioplasty with stenting is a safe and clinically effective method for treating atherosclerotic stenosis of the proximal segment of VA. In a cohort of 50 patients included in the study, low quality of life was observed prior to stenting of VA. Six months after the VA stenting, the quality of life of patients increasesin both physical and psychological aspects. The main problem remains to be a high incidence of restenosis or reocclusion of stents after primary and repeated endovascular intervention in the long-term postoperative period.

Bow hunter's syndrome in a patient with a right hypoplastic vertebral artery and a dynamically compressible left vertebral artery

This is a case report of a 48-year-old man with multiple transient ischemic attacks and a known hypoplastic right vertebral artery (VA) who presented after a syncopal event while turning his head to the left. The objective of this study is to demonstrate the necessity of proper diagnosis and management of cerebrovascular pathology including imaging and surgical intervention in patients with known anatomical anomalies. This study was conducted at Massachusetts, United States of America. Our patient's history was significant for a hypoplastic right VA and a stenotic segment of the right VA at the C3–C4 junction. There was also degeneration of the C3–C4 facet on the left, with osteophyte formation compressing the VA, and a fusion of the C2–C3 segment. Imaging demonstrated obliteration of the left VA flow with head rotation to the left and subsequent reconstitution of flow in the neutral position. After consultation, the patient decided to proceed with surgical management with an anterior cervical discectomy and fusion at the level of C3–C4. Symptoms of vertebrobasilar insufficiency including syncopal episodes resolved after treatment. VA anomalies, although uncommon, are important to understand. Our patient presented with an anomalous right VA, as well as severe degenerative changes to the C2/C3 vertebrae that contributed to the development of Bow Hunter's syndrome. It is essential that proper monitoring and follow-up has to be carried out in patients with abnormal cerebral vasculature to minimize the occurrence of Bow Hunter's syndrome.

Subclavian-to-Extracranial Vertebral Artery Bypass in a Patient With Vertebrobasilar Insufficiency: 3-Dimensional Operative Video.

Hemodynamic insufficiency from extracranial vertebral artery (VA) stenosis may be a primary cause for transient ischemic attacks in patients with vertebrobasilar insufficiency (VBI). Recent literature supports open or endovascular revascularization in selected patients. Although traditionally carotid-to-VA bypass was used to augment flow and alleviate symptoms of VBI, a subclavian artery (SA)-to-VA bypass avoids the risk of ischemic injury of the anterior intracranial circulation. We describe a SA-to-extracranial VA bypass in a 53-yr-old woman who presented with vertigo, dizziness, and syncope exacerbated by neck movements. An angiogram demonstrated complete bilateral proximal VA occlusions. The patient had collateral flow distally from muscular branches off the thyrocervical trunk and minimal flow through the anterior circulation. Neck movements appeared to reduce flow from the muscular branches, producing symptoms. Given the patient's symptoms, the radiographic findings, and the unsuitability of an endovascular procedure to augment flow, a left VA revascularization procedure was planned (either VA could have been the recipient for revascularization). Using an interposition saphenous vein (SV) graft (harvested by the cardiac surgical team), we augmented the posterior circulation with a left SA-to–VA (V3 segment) vascular bypass. The thyrocervical trunk was used as donor vessel because its caliber matches the SV graft and V3 segment. The horizontal part of the V3 segment was isolated in the J-groove of the C1 arch. Microsurgical end-to-end thyrocervical trunk-to-SV and end-to-side SV-to-VA anastomoses were performed, and flow was confirmed. Postoperative angiography showed patent flow through the graft and improved posterior circulation, with symptomatic improvement continuing at 6-mo follow-up. This report is exempt from informed consent. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx130 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Subclavian-to-Extracranial Vertebral Artery Bypass in a Patient With Vertebrobasilar Insufficiency: 3-Dimensional Operative Video","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_r8guqjyl"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosures Dr Taussky is a consultant for Covidien/ev3/Medtronic, unrelated to this work. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Morphometric study of the posterior arch of atlas vertebra in the Serbian population

Introduction. Groove for the vertebral artery and the suboccipital nerve, is located on the superior surface of the posterior arch of the first cervical vertebra (the atlas). Presence of bony variations may transform the groove into incomplete/complete canal, causing compression of its structures and consequently symptoms of vertebro-basilar insufficiency. The aim of the present study was to determine the incidence and extent of morphological variations of the posterior arch of the atlas vertebra. Material and Methods. The investigation was conducted on 41 atlas vertebrae, part of the Osteological Collection of the Department of Anatomy of the Faculty of Medicine in Novi Sad and the Faculty of Medicine in Nis. According to the shape of the posterior arch, the atlas vertebrae were classified into three classes. The measurements of maximum width and height diameters of the incomplete/complete canal for the vertebral artery were performed. All the measurements were done using open source software for image analysis, Image J. Results. The results of the study showed that in our sample of atlases the most common class was class I (78.05%), and class III the least frequent (7.32%). There was no statistically significant difference in the observed measurements of the atlas anatomical variations between the right and left side. Conclusion. Morphometric analysis of the superior surface of the posterior arch of the atlas vertebra has shown the existence of variations and their importance has been discussed.

Drug-eluting stents in the treatment of proximal vertebral artery stenosis

The objective of the study was to evaluate the efficacy of endovascular revascularization treatment using drug-eluting stents in patients with atherosclerotic proximal vertebral artery (VA) stenosis. Thirty-two patients (61 ± 10 years old) were implanted with 35 sirolimus and tacrolimus eluting stents (3 patients had them from two sides). 27 patients (84%) had vertebrobasilar symptoms at enrollment. All patients were pretreated with dual antiplatelet therapy. The intervention was technically successful in 89% cases. No stroke, myocardial infarction, or death occurred in perioperative period. On duplex scanning the stents remained completely functional. In the late postoperative period 29 (91%) patients, with 32 implanted stents were followed- up. The mean follow-up was 9.5 months. No stroke occurred in patients during this period. Recurrence of vertebrobasilar insufficiency symptoms was noted in 3 patients. VA renarrowing was detected in 16 (50%) arteries in 15 patients, and 12 (80%) of them were asymptomatic. Restenosis ≥50% (n = 13) and reocclusion (n = 3) were more frequent in those with implantation of tacrolimus eluting stents compared to those with sirolimus eluting stents: 10 (71%) of 14 observations to 6 (33%) of 18 cases (p = 0.1794), respectively. Stent fracture was observed in 2 cases (6%), followed by restenosis. Restenosis rate prevailed in men (p = 0.0173). Thus, stenting of VA extracranial portion is reasonably safe procedure with a good clinical effect. The use of drug-eluting stents looks promising but does not solve the problem of high restenosis rate in the late postoperative period.

Where did the clot go? An unusual complication of mechanical thrombectomy caused by malignancy related subclavian steal phenomenon in a patient with acute basilar artery occlusion

Subclavian steal is a relatively common vascular phenomenon usually caused by atherosclerotic disease. While symptoms are rare, arm claudication of the ipsilateral limb is most common, with paroxysmal symptoms of...