Vertebral Artery Insufficiency Research Articles

Teaching Neuro Images : Dynamic vertebral artery insufficiency

A 20-year-old healthy man presented with transient right upper monoparesis and brain MRI (figure, A) demonstrated left thalamic infarct. He presented 2 weeks later with left hemiparesis at basketball practice and right thalamic infarct (figure, B). Stroke risk factor workup was unrevealing. Conventional angiography demonstrated normal left vertebral artery course (figure, C and E), but dynamic left vertebral artery occlusion during 36° rightward head turn (figure, D and F). Bow hunter syndrome, first described in an archer,1 is eponymous for positional occlusion of the vertebral artery. This is associated with strokes from dynamic hypoperfusion. The patient remains symptom-free 1 month after microsurgical clip sacrifice of the left vertebral artery.

Use of Thrust Cervical Spinal Manipulative Therapy for Complicated Neck Pain: A Cross-Sectional Survey of Asia-Pacific Chiropractors.

Background Chiropractors often use manual thrust cervical spinal manipulative therapy (thrust-cSMT) to treat musculoskeletal neck conditions. We hypothesized <50% of surveyed Asia-Pacific chiropractors would report using thrust-cSMT given potential contraindications, and secondarily explored predictors of thrust-cSMT use. Materials and methods We designed, validated, achieved sufficient reliability, and disseminated a survey to explore thrust-cSMT use. The survey queried chiropractors' characteristics (e.g., years in practice, education level, time with patients, importance of subluxation), and use of thrust-cSMT for uncomplicated neck pain and vignettes describing vertebral artery disorders, Arnold-Chiari malformation, and anterior cervical discectomy and fusion (ACDF). We performed logistic regression for each vignette with thrust-cSMT as the dependent variable and chiropractor characteristics as covariates. Results There were 241 respondents, having 12.8±10.9 years in practice, representing >15 countries. Less than 50% of chiropractors reported the use of thrust-cSMT for each vignette, including vertebral artery insufficiency (14%) and stenosis (17%), Arnold-Chiari type I (18%) and type II (5%), C5/6 ACDF (39%) and C3-6 ACDF (27%). Regressions identified significant predictors of increased or decreased use of thrust-cSMT including time spent with new patients, focus on subluxation, degree, group practice environment, use of thrust-cSMT on a healthy patient, and hours reading scientific literature (P<.05 for each). Conclusions This study was the first to chiropractors' use of thrust-cSMT for complicated neck pain and found that most Asia-Pacific chiropractors reported avoiding this treatment in the presence of a potential treatment contraindication. The use of thrust-cSMT in complicated neck pain may be related to practice characteristics. However, further research is needed to identify specific reasons why chiropractors use or avoid thrust-cSMT.

The Differential Diagnosis and Treatment of a Patient With Concurrent Cervicogenic Headache, Concussion, and Hyperlaxity

Background Patients presenting with concurrent headache types present a challenge in diagnosis and subsequent treatment. Cervicogenic headache, concussion, and cervical artery dysfunction may present with similar and often overlapping symptoms and impairments. These include but are not limited to neck pain and headache, dysphagia, dysarthria, diplopia, dizziness, drop attacks, nystagmus, nausea, and nervousness. Case Presentation A 40-year-old female presented with a history of insidious onset left-sided neck pain, occipital headache, and subsequent concussion history. Additional symptoms included intermittent dizziness, nausea/vomiting, and intolerance of noise/computers. Cervicogenic symptoms were ruled in with upper cervical mobility tests. Vestibular symptoms were provoked with Vestibular/Ocular Motor Screening. Risk factors were carefully considered; while the patient demonstrated no increase in symptoms with vertebral artery insufficiency testing, potential vascular involvement could not be completely ruled out. Discussion This case details the clinical reasoning applied to the differential diagnosis and treatment of a complex headache presentation in the presence of conflicting symptoms. JOSPT Cases 2022;2(2):103–108. doi:10.2519/josptcases.2022.10676

Vertebrobasilar insufficiency caused by cervical aneurysmal bone cyst – Case report

Aneurysmal bone cysts (ABC) are benign bone tumors of relatively rare occurrence. Most of the lesions occur at long bones, vertebrae and flat bones. However, the cervical vertebrae involvement is uncommon. Occasionally, the ABCs compress the spinal cord and nerve roots. Depending on the level of involvement and the extent of spinal cord compression, a wide variety of neurological symptoms and signs may be noted later, ranging from mild radiculopathy to complete paraplegia or tetraplegia. A case of aneurysmal bone cyst involving the second and third cervical vertebrae in a 15 years old patient, causing compression of the right vertebral artery and subsequent vertebrobasilar insufficiency is reported. We also discuss the clinical manifestations of the vertebrobasilar insufficiency, of the spinal compression, and the surgery treatment performed in this case.

Cervical spondylosis: a rare and curable cause of vertebrobasilar insufficiency

Spondylotic vertebral artery (VA) compression is a rare cause of vertebrobasilar insufficiency and stroke. A 53-year-old man experienced multiple brief vertebrobasilar transient ischemic attacks (TIAs) and strokes, not apparently triggered by neck movements. Brain magnetic resonance imaging (MRI) documented consecutive infarcts, first in the left then right medial posterior inferior cerebellar artery (PICA) territories. Angiography showed two extracranial right vertebral artery (VA) stenoses, left VA hypoplasia, absence of left PICA and a dominant right PICA. Computed tomography angiography revealed right VA compression by osteophytes at C5-C6 and C6-C7 levels. No further vertebrobasilar insufficiency symptoms occurred in the 65 months following VA surgical decompression. Our literature review found 49 published surgical cases with vertebrobasilar symptoms caused by cervical spondylosis. Forty cases had one or more brief TIAs frequently triggered by neck movements. Three cases presented with stroke without prior TIA, with symptoms suggesting a top of the basilar artery embolic infarcts (one combined with a PICA infarct). Six cases had both TIAs and minor stroke. VA compression by uncovertebral osteophytes at the C5-C6 level was common. Dynamic angiography done in 38 cases systematically revealed worsening of VA stenosis or complete occlusion with either neck extension or rotation (ipsilateral when specified). Contralateral VA incompetence was found in 14 patients. Spondylotic VA stenosis can cause hemodynamic TIAs and watershed strokes, especially when contralateral VA insufficiency is combined to specific neck movements. Low-amplitude neck movement may suffice in severe cases. Embolic vertebrobasilar events are less frequent. VA decompression from spondylosis may prevent recurrent ischemic episodes.

Bilateral Cerebellar Infarcts from Vertebral Artery Insufficiency Caused by Cervical Osteophytes

Abstract Background: In previous reports, the patients are described to have transient symptoms from physiologic rotation or extension of the cervical spine, resulting from a cervical osteophyte compressing the vertebral artery and causing vertebral artery insufficiency, known as Bow Hunter syndrome. Methods: An 85-year-old female presented with new onset occipital headaches, nausea, vomiting and vertigo that were not precipitated by change in head position. Patient had bilateral cerebellar infracts. Patient underwent decompression and instrumented stabilization of the cervical spine from the posterior approach. Results: At one-year follow-up, patient remained stroke free with patent vertebral artery. Conclusion: To our knowledge, this is the first report of bilateral infraction from a vertebral artery insufficiency caused by cervical osteophytes without history of transient symptoms from movement of the head or neck, a variant of the Bow Hunter syndrome. Anterior versus posterior approach for vertebral artery insufficiency from osteophytic compression should be primarily based on location of the pathology and not the cervical level of involvement.

The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases

Anterior cervical spine operations (ACSO) are generally considered to be safe and effective, but the vertebral artery (VA) is at risk during the procedure. Because the consequences of VA injury can be catastrophic, properly managing a VA injury is very important. However, due to the rarity of these injuries, there is no agreed upon treatment strategy. Studies were identified for inclusion in the review via sensitive searches of electronic databases through 31 December 2011. All cases included in the review were qualitatively analyzed to explore the relationship between type of VA injury management and neurological complications. Seventeen articles describing 39 cases of VA injury during ACSO were included in this study. Seven patients (17.9 %) had neurological complications followed by VA insufficiency. Two patients (5.1 %) had root damage due to ligation. One case (2.6 %) resulted in intraoperative death due to fatal bleeding. Delayed vascular complications were identified in nine (45.0 %) of the 20 patients that underwent only tamponade or hemostatic agent during the operation. Four patients underwent intraoperative endovascular treatment, and three of these patients had a cerebral infarction. All three patients who underwent clipping also had neurological complications. The five patients treated by direct repair did not have any complications. Our review suggests the management of VA injury should be considered in order listed: (1) performing tamponade with a hemostatic agent, (2) direct repair, (3) postoperative endovascular procedures to prevent delayed complications. If tamponade fails to achieve proper hemostasis, additional procedures as endovascular embolization, clipping and ligation should be considered but carry the risk of neurological complications. Because of the limitations of this review, further studies are recommended with larger sample sizes.

Clinical observation on needling tendon for cervical spondylosis causing vertebral artery insufficiency

Objective To observe the clinical effect of needling tendon for cervical spondylosis causing vertebral artery insufficiency.

Obervation on the effectiveness of nursing mode about health interview for patients with vbivertebrobasilar

Objective To explore the effectiveness of nursing mode about health interview for patients with vbi vertebrobasilar. Methods Fifty one cases of vertebrobasilar insufficiency patients were randomly divided into the observation group (25 eases) and the intervention group (26 cases). Both of two groups adopted conventional treatment and care of vertebrobasilar insufficiency. Intervention group was received health care and interview model in practice at the same time, that is to say: taking some measures to patients of vertebral artery insufficiency , such as to be admitted to the hospital reception, hospital information support, discharged from hospital and health behavior guidance and regular telephone follow-up after discharge. All in all, to implement the entire process seamless care. Both of groups were evaluated with Anxiety Self-appraising Scale (SAS) . Results After first three weeks of admission to hospital, SAS scores of the intervention group were significantly lower than that of control group (average P <0.01), while the health evaluation was also better in observation group. Conclusions If applying the interview to health care model on the patients of vertebrohasilar insufficiency , it is good to improve unhealthy psychology, disease-related knowledge and compliant behavior on vrtebrohasilar insufficiency. What' s more, it can lower the rate of relapse, improve the quality of life, reduce the burden on family and society and accelerate professional growth of nurses at the same time. Key words: Vrtebrobasilar insufficiency; Quality of life; Interview on health care model

Fatal cerebellar stroke following emergency endovascular stent grafting of a leaking thoracic aortic aneurysm: A case report

Stent-grafting of thoracic aortic diseases has developed as an alternative therapeutic modality in thoracic aneurysm management. Postprocedural complications include mortality, endoleaks, paraplegia and stroke. Other complications that may arise in cases of overstenting the origin of the left subclavian arther include left upper limb ischemia, subclavian steal syndrome and stroke. Posterior circulation strokes due to vertebral artery insufficiency have been reported in the past. In the present case, a fatal stroke caused by a cerebellar infarct culminating in the death of a patient with a leaking thoracic aortic aneurysm is reported. Medical personnel as well as patients should be aware of this possible complication. Vigilance in assessing the contralateral cerebral circulation before the procedure is a prerequisite in less acute circumstances.

Foramen arcuale: anatomical study and review of the literature

The neurosurgical literature is lacking information on the so-called foramen arcuale. When this foramen is present, the vertebral artery (VA) travels through it after exiting the transverse foramen of the atlas and prior to entering the cranium. The authors performed a study in 60 cadavers to determine the incidence of the foramen arcuale and ascertain morphometric information on its anatomy. In specimens in which the foramen arcuale was observed, the authors studied the relationship between it and the VA. The authors identified a foramen arcuale in 5% of specimens. The mean length and thickness of the osseous struts that converted the groove for the VA into the foramen arcuale were 7.0 and 2.0 mm, respectively. The mean area of the identified foramina was 14.2 mm2. The mean area of the ipsilateral C-1 transverse foramina was 18 mm2 in specimens with a foramen arcuale. The mean measurements of the proximal, intraforaminal (foramen arcuale), and distal diameter of the V3 segment of the VA at the level of the foramen arcuale were 6, 4, and 5 mm, respectively. In all specimens the authors noted that the intraforaminal part of the V3 segment was grossly compressed. The authors found that the foramen arcuale may compress the V3 segment of the VA. Based on their postmortem study, however, they cannot conclude that compression at this location results in symptomatic VA insufficiency. Based on their review of the literature, it seems that symptomatic compression of the VA at this location may be alleviated in some patients with decompressive procedures.

Rotational vertebral artery insufficiency resulting from cervical spondylosis: case report and review of the literature

Background Four cases of vertebrobasilar insufficiency secondary to osteophyte formation at C5-C6 have been reported in the literature. In this article, we report the fifth such case and discuss the utility of dynamic computed tomographic angiography (CTA) in the management of this disorder. Case Description A 55-year-old right-handed man presented for evaluation after syncopal episodes associated with right-head turning. Workup revealed cervical spondylosis with stenosis. The C5-C6 level was significantly affected. Dynamic angiography revealed obstruction of vertebral artery flow with right-head turning secondary to an osteophyte at the foramen transversarium at C5-C6. This patient underwent a C5-C6 anterior cervical discectomy and fusion. He also underwent unroofing of the vertebral artery and drilling of the osteophyte at the foramen transversarium. Postoperative CTAs reveal reconstitution of flow in the vertebral artery with head turning. Conclusion The utility of dynamic 3-dimensional CTA in the management of this disorder avoids the risk of invasive studies.

Clinical observation of puerarin in treating patients with vertebral artery insufficiency due to cervical spondylosis: a report of 123 cases

Clinical observation of puerarin in treating patients with vertebral artery insufficiency due to cervical spondylosis: a report of 123 cases

環椎後頭骨癒合症の２例

Assimilation of the atlas is a rare disease, and this condition is characterized by a partial or complete congenital union between the atlas and the base of the occiput. We report two cases of assimilation of the atlas.A 32-year-old male had been suffering from neck stiffness, progressive numbness of the extremities and walking disturbance since he was 13 years old. Assimilation of the atlas associated with atlantoaxial instability was seen and spinal cord was compressed at the atlanto-occiput junction severely on MRI. Removal of the posterior arch of the atlas and occipito-cervical fusion was pertormed using instruments and the symptoms improved.A 51-year-old female lost consciousness which driving and collided into a concrete fence. She regained consciousness after a few minutes but experienced walking disturbance and right hand numbness. No intracranial lesion was found but MRI indicated a high signal area in the spinal cord at the occpitocervical junction. In addition to spinal cord injury, computed tomography revealed assimilation of the atlas, atlantoaxial subluxation, and os odontoideum. Loss of consciousness was considered resulting from vertebral artery insufficiency. After more or less the same surgery as the previous case, she could leave the hospital by walking and lead daily life without difficulties.

Cerebellar infarction secondary to os odontoideum.

A 43-year-old man developed cerebellar infarction due to atlantoaxial dislocation associated with os odontoideum. Cervical X-ray films confirmed os odontoideum, and conventional angiography revealed irregular narrowing of the right vertebral artery at the axis level. A correlation between the vertebral artery lesion and atlantoaxial instability was shown with 3-dimensional (3-D) computed tomographic (CT) angiography. This is the first case of atlantoaxial dislocation with vertebral artery stenosis demonstrated 3-D CT angiography. 3-D CT angiography can support the conventional angiography with respect to the diagnosis and management of vertebral artery insufficiency associated with occipitocervical deformity.

Vertebral artery insufficiency as a possible mechanism for sudden infant death – in vivo evidence does not support findings from postmortem studies

Recent postmortem studies have suggested that sudden infant death syndrome (SIDS) might involve an underlying, gradual brain stem injury caused by repeated episodes of transiently compromised brain stem circulation. Autopsy studies have also reported that vertebral artery occlusion due to head rotations, such as occurs, e.g. during prone sleeping, would be a physiological phenomenon of infant atlantooccipital junction. The present study was undertaken to examine whether vertebral artery insufficiency does truly occur in live infants during such head rotations. We studied by transcranial doppler sonography the blood flow velocity of the basilar artery (BA) in 27 infants during head rotation from straight position to maximal rotation in three directions (left, right, dorsiflexion). No significant change in BA blood flow was seen between any head positions. Weight and gestational age, but not arterial pressure or hematocrit, of the infants were correlated with blood flow velocity. Our results suggest that brain stem circulation in live infants may not be compromised due to changing the head position, which is inconsistent with the postmortem findings showing insufficiency of brain stem circulation in both controls and those succumbed to SIDS. We hence propose that the brain stem pathology observed with SIDS is likely caused by other factors (e.g. systemic disturbance) rather than by mechanical obstruction of brain stem circulation.

A possible correlation between vertebral artery insufficiency and degenerative changes in the cervical spine.

We studied 130 patients, aged 20 to 81 years, with symptoms of tinnitus, vertigo or dizziness. Radiological examinations revealed degenerative changes in the cervical spines of all patients such as discopathy or osteophytes. Head and neck and neurological examinations ruled out other symptoms apart from vertebrobasilar artery flow insufficiency. The vertebrobasilar arteries were examined by means of a color Doppler ultrasonograph using duplex scanning. The correlation coefficient (CC) defining the relationship between the number of patients with abnormal blood flow and the total number of patients with radiologically confirmed changes in the cervical spine was 41.5%. When patients were separated by age, the value of the CC coefficient increased proportionally according to age, changing from 0 to 79.1%. Use of the Doppler ultrasonograph was found to be a safe and non-invasive diagnostic method that enabled us to assess the influence of degenerative changes in the cervical spine on hemodynamic disturbances in the inner ear and brain stem. Our findings demonstrated a pathological decrease of vertebral artery flow velocity in relationship to degenerative changes in the cervical spine.

17.5 Surgical treatment of vertebral artery insufficiency

17.5 Surgical treatment of vertebral artery insufficiency

Vertebral artery occlusion associated with cervical spine trauma. A prospective analysis.

Radiographs and charts of 61 patients sustaining cervical spine trauma were studied prospectively to determine the incidence of vertebral artery injuries and possible correlative factors. Statistical analysis was conducted using chi-square testing of a two-way classification system. To elucidate the incidence of vertebral artery injuries associated with cervical spine trauma, and to determine the value of various factors in predicting the existence of a vertebral artery injury. During a 7-month period, 61 patients (41 male patients, 20 female; average age, 40.3 years) with cervical spine trauma were studied. All patients admitted to the authors' hospital with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of their cervical spine. All magnetic resonance angiographies were examined for vertebral artery injury. Data on demographics and the injury were recorded. Complete disruption of blood flow through the vertebral artery was demonstrated by magnetic resonance angiography in 12 of the 61 patients (19.7%). Ten of the 12 patients (83%) had either flexion distraction or flexion compression injuries. Age, sex, mechanism of injury, neurologic impairment, and associated injuries were not statistically significant in predicting the presence of a vertebral vessel occlusion. The findings in this study may support the need for vertebral vessel evaluation in selective patients, particularly those with flexion injuries and with neurologic symptoms consistent with vertebral artery insufficiency syndrome that do not correlate with the presenting bone and soft-tissue injuries.

Relation between overhead work and complaints of pear and apple orchard workers.

The relation between working posture in overhead work and the complaints of farmers cultivating pears and apples were investigated by comparing pear work with apple work. The same 20 male and 28 female orchard workers were questioned about complaints associated with thinning out pears and bagging them, and bagging apples. The angle of forward flexion in the shoulder and neck extension was also measured in each job. The prevalence of tiredness, stiffness and pain in the neck, shoulders and arms was significantly higher in thinning out pears and bagging them than in bagging apples. Dizziness and tinnitus among female workers was more frequent in thinning pears. The posture of raising arms and bending the head backwards was higher in thinning and bagging pears. These results suggest that the working postures of elevated arms and backward head bending can cause symptoms in the neck, shoulders and arms. In some cases, they may also lead to symptoms of vertebral artery insufficiency.