Vertebral Artery Occlusion Research Articles

Asymptomatic severe occlusion of the internal carotid artery (ICA) in a Chinese patient with multiple cerebrovascular and cardiac stenoses

Abstract This is a case report about chronic occlusion of internal carotid artery and vertebral artery with mild clinical transient neurological deficit. This patient also had severe stenosis of the coronary circulation.

Atlantoaxial Stabilization Using C1 and C2 Laminar Screw Fixation.

We describe the use of a C1 laminar screw in combination with a C2 laminar screw as a salvage technique to treat two patients, one with persistent first intersegmental artery and the other with vertebral artery occlusion after cervical spine fracture. The combined use of C1 and C2 laminar screws allows for good fixation of the atlantoaxial joint with a lower risk of vertebral artery injury; therefore, it can be an alternative surgical procedure for patients with congenital or traumatic anomalous vertebral artery.

Moyamoya disease with occlusion of bilateral vertebral arteries and the basilar artery fed by the collateral vessels of vertebral arteries: A rare case report

The main change of moyamoya disease (MMD) is steno-occlusion at the terminal portion of the bilateral internal carotid arteries (ICAs). Occlusion of distal portions of the bilateral vertebral arteries (VAs) in MMD has never been reported. An 18-year old female was admitted with repeated headache for 13years. Cerebral digital subtraction angiography (DSA) demonstrated occlusion of bilateral ICAs at their terminal portions, moyamoya vessels at the skull base, occlusion of bilateral distal VAs and the basilar artery (BA) fed by the tortuous collateral vessels arising from the cervical segment of VAs. We report this unique case for its rarity and discuss its mechanism.

Efficacy and safety of direct aspiration first pass technique versus stent-retriever thrombectomy in acute basilar artery occlusion-a retrospective single center experience.

The study aimed to compare efficacy and safety of aspiration thrombectomy (AT) to stentriever thrombectomy (SRT) in patients with basilar artery (BA) occlusion (BAO). We retrospectively included patients with the following characteristics: acute BAO or occlusion of the intracranial vertebral artery (ICVA) and endovascular therapy (EVT) with stentriever (SRT) or aspiration thrombectomy (AT). Additional extra- but not intracranial EVT and intravenous thrombolysis (IVT) were allowed. Between January 2013 and April 2016, 33 patients fulfilled the criteria (13 treated with SRT, 20 with AT). Prior to EVT, 23 (70%) patients received IVT. The proximal intracranial occlusion was ICVA in 2 patients, proximal BA in 5 patients, middle BA in 20 patients, and distal BA in 6 patients. Mean time to treatment was 334min (95% CI 276-391min). Procedure duration differed significantly (p=0.002) as follows: 97min with SRT (95% CI 69-124min) and 55min with AT (95% CI 43-66min). Recanalization (arterial occlusive lesion (AOL) 2/3) was achieved in 26 patients (79%). Complete recanalization (AOL 3) happened more often with AT (75% (95% CI 65-85%)) compared to SRT (46% (95% CI 32-60%)). Conversion rate 6% (two patients). Hemorrhages occurred in 12 (36%) patients, periprocedural complications in eight (three dissections, five embolizations to new territory) (no group difference). Ten patients (30%) had a favorable outcome (mRS ≤3) at discharge; mortality rate was 24% (eight deaths) (no group difference). In primarily embolic BAO, aspiration thrombectomy was faster, effective and not detrimental to outcome as compared to stentriever thrombectomy. Thus, it may be justified to use aspiration thrombectomy as first-line treatment in these patients.

Multiple Infarctions Due to Vertebral Arterial Occlusion Associated with Atlantoaxial Subluxation in Patients with Rheumatoid Arthritis: A Case Report

Rheumatoid Arthritis (RA) is associated with a high incidence of destruction of multiple joints, including Atlantoaxial Subluxation (AAS). Because the Vertebral Arteries (VA) is near the Atlantoaxial (AA) joint, VA occlusion may occur due to AAS. Since the VA supplies blood to the cerebellum and brainstem, serious symptoms can develop if infarction occurs due to VA occlusion. In this case report of a 64-year-old female RA patient, CT angiography demonstrated a dissecting aneurysm and the occlusion of the left VA at the AA joint, attributed to the one-sided destruction of the C1/C2 lateral mass, leading to frequent cerebellum infarctions. Vertigo and neck pain in the extension position disappeared after C1/C2 posterior fixation, and infarctions originating from VA occlusion never recurred after surgery. As the positional occlusion of VA in AAS itself has become relatively uncommon since the use of biological preparations for RA treatment, the authors describe a case in which C1/C2 fixation is effective for preventing neck pain, deterioration of neurological findings and the recurrence of cerebellum infarctions due to positional VA occlusion.

An unusual case of posterior circulation stroke

Anterior circulation strokes are far more common than posterior circulation strokes. Approximately 80–85% of all strokes are ischemic, and 20% of lesions occur in the vertebrobasilar territory. Most common cause of lateral medullary syndrome is vertebral artery occlusion. Although vertebral artery also supplies the spinal cord, involvement of the spinal cord in a case of lateral medullary syndrome has not been reported before. Pyramidal tract involvement in lateral medullary syndrome can occur due to medial extension of infarct in the medulla or caudal extension into the spinal cord. Here, we report an interesting case of lateral medullary syndrome caused by vertebral artery occlusion with cervical cord infarct presenting as quadriparesis.

Iatrogenic Vascular Injuries Due to Spinal Surgeries: Endovascular Perspective.

Iatrogenic vascular injuries due to spinal surgeries are rare but serious complications. Surgical management of these injuries is challenging with high morbidity rates. In this study we aim to present the results of endovascular management of iatrogenic vascular injuries due to spinal surgeries. We retrospectively reviewed 11 patients (5 male, 6 female) who had vascular injuries due to cervical and lumbar spinal surgeries. Clinical findings were bleeding (n=5), leg edema (n=6) and right heart failure with severe dyspnea (n=1). The age range of the patients were between 42-67 (mean: 57.1). Six patients were reviewed with imaging before the procedures and the rest of the patients (n=5) were directly referred to the angiography unit for diagnosis and possible endovascular treatment. The types of surgeries were; cervical surgery (n=5) and lumbar disc operation (n=6). The type of vascular injuries were; vertebral artery stenosis (n=1), vertebral artery pseudoaneurysm (n=3), vertebral artery occlusion (n=1) and iliac arteriovenous fistula (n=6). The type of endovascular treatments were; parent artery occlusion (PAO) (n=2), covered stent graft implantation (n=6) and intrasaccular coil embolization of pseudoaneurysm (n=1). The remaining 2 patients were managed conservatively. No major complications or mortality occured during endovascular interventions. No bleeding or ischemia occured in the follow-up period. Iatrogenic vascular injuries due to spinal surgeries are rare but serious complications. Endovascular interventions are safe and effective in the diagnosis and treatment of such vascular injuries.

Posterior atlantoaxial fusion using a C2 transverse foramen-penetrating screw: A technical note.

Background:Although recent development of screw instrumentation techniques for rigid fixation of the atlantoaxial joint has increased surgical options, patients in whom screws of any type cannot be safely placed are sometimes encountered. We present a unique surgical technique for C1-2 transarticular screw placement utilizing a novel trajectory.Methods:A 35-year-old male with a history of Down's syndrome and cognitive dysfunction with hyperkinesis spontaneously developed rapid onset of tetraparesis and gait disturbance. Radiographs of the cervical spine revealed atlantoaxial subluxation (AAS) that could not be reduced. Computed tomography (CT) of the head showed multiple subacute cerebral infarctions in the territory of the right vertebral artery (VA). Three-dimensional CT angiography of the craniovertebral junction additionally confirmed right VA occlusion at the C2/3 level, a left C2 origin of the posterior inferior cerebellar artery, and hypoplasia of the bilateral C2 pedicles/C2 lamina. Because traditional screw-placement was not feasible, we performed a unique atlantoaxial fusion utilizing a C2 transverse foramen-penetrating screw with iliac bone grafting performed under neuronavigation.Results:The postoperative course was uneventful, and the patient regained the ability to ambulate, returning to his previous level of function. The CT of the cervical spine 12 months postoperatively showed rigid bony C1-C2 fusion, without recurrence of stroke.Conclusion:We introduced a novel C1-C2 transarticular screw-placement technique in which the trajectory went through the ipsilateral VA foramen due to already extent VA occlusion.

Concurrent infarction in bilateral middle cerebellar peduncles: Rare presentation of stroke

Although some pathologies like demyelination have predilection for middle cerebellar peduncles (MCPs), infarction of bilateral MCP simultaneously is an exceedingly rare presentation of stroke. Patient was a 70-year-old smoker and hypertensive male presented with acute onset vertigo, imbalance while walking and slurred speech for 2 days and examination revealed horizontal nystagmus bilaterally, scanning speech with cerebellar signs and Modified Rankin Score (MRS) of 3. Magnetic resonance imaging brain showed symmetrical areas of diffusion restriction in both MCP, and there was occlusion of bilateral vertebral arteries (partial occlusion of right and complete occlusion of left) and basilar artery in computed tomography angiography. Oral antiplatelet with antihypertensive medication was started along with gait training and speech therapy. Patient had gradual and significant recovery and his MRS improved to 2 after 3 months' follow-up. Hypoperfusion along with atherothrombotic occlusion of vessels can be probable explanation to the bilateral infarction in MCPs which forms important watershed zone in posterior circulation of the brain.

Effects of ellagic acid pretreatment on renal functions disturbances induced by global cerebral ischemic-reperfusion in rat.

Objective(s):Global cerebral ischemia-reperfusion (GCIR) causes disturbances in brain functions as well as other organs such as kidney. Our aim was to evaluate the protective effects of ellagic acid (EA) on certain renal disfunction after GCIR.Materials and Methods:Adult male Wistar rats (n=32, 250-300 g) were used. GCIR was induced by bilateral vertebral and common carotid arteries occlusion (4-VO). Animal groups were: 1) received DMSO/saline (10%) as solvent of EA, 2) solvent + GCIR, 3) EA + GCIR, and 4) EA. Under anesthesia with ketamine/xylazine, GCIR was induced (20 and 30 min respectively) in related groups. EA (100 mg/kg, dissolved in DMSO/saline (10%) or solvent was administered (1.5 ml/kg) orally for 10 consecutive days to the related groups. EEG was recorded from NTS in GCIR treated groups.Results:Our data showed that: a) EEG in GCIR treated groups was flattened. b) GCIR reduced GFR (P<0.01) and pretreatment with EA attenuated this reduction. c) BUN was increased by GCIR (P<0.001) and pretreatment with EA improved the BUN to normal level. d) Serum creatinine concentration was elevated by GCIR but not significantly, however, in EA+GCIR group serum creatinine was reduced (P<0.05). e) GCIR induced proteinuria (P<0.05) but, EA was unable to reduced proteinuria.Conclusion:Results indicate that GCIR impairs certain renal functions and EA as an antioxidant can improve these functions. Our results suggest the possible usefulness of ellagic acid in patients with brain stroke.

Endovascular One-stage Bilateral Vertebral Artery Occlusion for a Patient with Atlanto-axial Fracture Associated with Bilateral Vertebral Artery Injury

Endovascular One-stage Bilateral Vertebral Artery Occlusion for a Patient with Atlanto-axial Fracture Associated with Bilateral Vertebral Artery Injury

Delayed bilateral vertebral artery occlusion after cervical spine injury: a case report.

There are considerable risks for the secondary spinal cord injury and the initial and/or delayed vertebral artery occlusion in cases of cervical fracture dislocation. An 86-year-old man was injured in a car accident and was diagnosed with no fracture or dislocation of the cervical spine by the emergency physician. However, he was transferred to our hospital 3 days later because he had motor weakness that was evaluated to be 32 points (out of 50 points) on the upper limb American Spinal Injury Association (ASIA) motor score and was diagnosed with spontaneously reduced fracture dislocation at C5/6. Magnetic resonance images revealed that the bilateral vertebral arteries were occluded, and there were some microinfarction lesions in the brain. On the first visit to his previous doctor, he was found to have a flow void in the right vertebral artery. This indicated that it was occluded during the waiting period at his previous doctor. On the day of his arrival at our hospital, the patient underwent a C5/6 posterior spinal fusion. Three months after surgery, he recovered to 46 points on the upper extremity ASIA motor score, and blood flow in the left vertebral artery was resumed. Early reduction and stabilization are necessary for cervical spine fracture dislocation; however, it is important not only for the prevention of the secondary injury but also for the reduction of the risk of vertebral artery occlusion.

Posterior Fossa Craniectomy with Endovascular Therapy of Giant Fusiform Basilar Artery Aneurysms: A New Approach to Consider?

The prognosis of unruptured giant basilar artery (BA) aneurysms is very poor. No treatment has shown efficacy in survival. This pilot case-control study examines the overall survival (OS) benefit of combined surgical and endovascular management of giant BA aneurysms. Combined treatment including posterior fossa craniectomy followed by endovascular treatment was performed in 3 patients with giant BA aneurysms. OS of the 3 patients was compared with a control group of 6 patients (ratio 1:2) treated with the endovascular procedure only. The mean survival time was 32.6 months in the craniectomy group (SD 9.01, 95% confidence interval [14.9, 50.3]) and 3.5 months in the control group (SD= 2.08, 95% confidence interval [0.001, 7.6]; Mantel-Cox test P < 0.04). At mean follow-up of 36.5 months (SD 10.2), 2 of 3 patients had a favorable outcome with a Glasgow Outcome Scale score of 5. Univariate analysis determined that women had a statistically higher OS than men (33.7 months vs. 3.058 months for men; log-rank test P= 0.011). A similar outcome was obtained in the presence of a circulating posterior communicating artery (P= 0.03) and in the presence of an endovascular right vertebral artery occlusion (P= 0.022). Our study suggests that preventive posterior fossa craniectomy increases significantly OS of patients with giant BA aneurysms.

A modified method to reduce variable outcomes in a rat model of four-vessel arterial occlusion

Objectives: Rat models of global cerebral ischemia (GCI) are essential to study potential treatment strategies against stroke in humans. However, nonvisual electrocoagulation of vertebral arteries often leads to incomplete occlusion that may prevent the creation of a successful model.Methods: Therefore, we used a modified method in which the vertebral arteries were safely visualized and electrocauterized between the first and second transverse processes through a dorsal incision. Twenty-four hours later, GCI was induced by transient bilateral common carotid arterial occlusion using microvascular clips. The clips were removed after 10, 20, or 30 min of four-vessel occlusion.Results: Digital subtraction angiography demonstrated complete occlusion of the rat vertebral arteries. In the 20-min GCI group, the rats were monitored for 1, 3, 5, or 7 days followed by histological analysis. The results showed that neuronal death in the CA1 subregion occurred almost linearly between 1 and 3 days of recovery. Tape removal test was used for up to 7 days after 20 min of GCI or sham operation. The latency time was found to be significantly increased 1 to 7 days after GCI compared with sham.Conclusions: In conclusion, this modified model provides a reliable tool for ischemic stroke research.

Higher Stroke Risk with Lower Blood Pressure in Hemodynamic Vertebrobasilar Disease: Analysis from the VERiTAS Study

Despite concerns regarding hypoperfusion in patients with large-artery occlusive disease, strict blood pressure (BP) control has become adopted as a safe strategy for risk reduction of stroke. We examined the relationship between BP control, blood flow, and risk of subsequent stroke in the prospective Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study. The VERiTAS study enrolled patients with recent vertebrobasilar (VB) transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion of vertebral or basilar arteries. Hemodynamic status was designated as low or normal based on quantitative magnetic resonance angiography. Patients underwent standard medical management and follow-up for primary outcome event of VB territory stroke. Mean BP during follow-up (<140/90 versus ≥140/90 mm Hg) and flow status were examined relative to subsequent stroke risk using Cox proportional hazards analysis. The 72 subjects had an average of 3.8 ± 1.2 BP recordings over 20 ± 8 months of follow-up; 39 (54%) had mean BP of<140/90 mm Hg. The BP groups were largely comparable for baseline demographics, risk factors, and stenosis severity. Comparing subgroups stratified by BP and hemodynamic status, we found that patients with both low flow and BP <140/90 mm Hg (n = 10) had the highest risk of subsequent stroke, with hazard ratio of 4.5 (confidence interval 1.3-16.0, P = .02), compared with the other subgroups combined. Among a subgroup of patients with VB disease and low flow, strict BP control (BP <140/90) may increase the risk of subsequent stroke.

Vertebral Artery Occlusion and Recanalization After Cervical Facet Dislocation

To investigate clinical features of vertebral artery (VA) occlusion and recanalization after cervical facet dislocation. During a 2-year period from January 2014 to December 2015, 29 consecutive patients with cervical facet dislocation were treated in investigator group. VA occlusion and recanalization were identified retrospectively by magnetic resonance imaging (MRI) at the time of injury and follow-up. VA occlusion occurred in 6 of the 29 patients (20.7%). All patients were unilateral occlusion and had no vertebrobasilar symptoms. Surgical anterior spinal fusion was performed in 5 patients, and 1 was treated by posterior fusion. Follow-up MRIs revealed VA recanalization in 5 patients. One patient did not undergo MRI because he died of respiratory failure. The time course for VA recanalization was from 6 days after injury to 4 months after operation depending on the length of VA occlusion. A fifth of patients with cervical facet dislocation will develop VA occlusion with rare symptomatic vertebrobasilar ischemia. VA recanalization occurs mainly within the first 4 months after injury, regardless of the length of VA occlusion.

Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations—Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke

Patients suffering from acute atherothrombotic occlusion of the proximal vertebral artery (VA) and concomitant basilar artery (BA) occlusion present a grim prognosis. We describe our experience in the endovascular recanalization of tandem vertebrobasilar occlusions using endovascular techniques. The BA was accessed through the normal VA (clean-road) or the occluded, thrombotic VA (dirty-road), and stentriever-based thrombectomy was performed using antegrade or reverse revascularization variants. Seven patients underwent successful stentriever-assisted mechanical thrombectomy of the BA and five sustained concomitant VA revascularization. Stroke onset to endovascular intervention initiation (time-to-treatment) ranged from 4.5–13hours (mean 8.6). In two of seven patients, the BA occlusion was approached with a ‘clean-road’ approach via the contralateral VA; in five of seven patients, a ‘dirty-road’ approach via the occluded VA was used. Mean time-to-recanalization was 66minutes (range 55–82). There were no perforations, iatrogenic vessel dissections, or other technical complications. Four patients presented mild-to-moderate disability (modified Rankin Scale [mRS] 0–3) at 3months, one remained with moderate-to-severe disability (mRS 4), and two patients died on days 9 and 23 after their strokes. Follow-up ranged from 6–45months (mean 24months). In selected patients with acute VA-BA occlusion, stentriever-based thrombectomy performed through either the patent or the occluded VA, may be feasible, effective, and safe. Clinical outcomes in these patients seem to equipoise the neurological outcome of patients with successful revascularization for isolated BA occlusion. This unique pair of occlusions confirms the role of VA ostium stenosis as a cause of vertebrobasilar stroke.

Anterior Spinal Artery Infarct Secondary to “Rotatory Atlantoaxial Subluxation” in a Pediatric Patient: A Case Report and Review of the Literature

Spinal cord infarction in children is a rare condition that is becoming more widely recognized. There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment options, and prognosis of anterior spinal artery infarction following rotatory atlantoaxial subluxation. In many children, the cause of spinal cord ischemia in the absence of vertebral fracture is unknown and is often wrongly diagnosed. Imaging diagnosis of spinal cord ischemia is often difficult due to the small transverse area of the cord, cerebrospinal fluid artifact, and inadequate resolution. The prognosis depends on the level of spinal cord damage, early identification and reversal of ischemia, and follow-up with intensive physical therapy and medical support. In addition to summarizing the literature on spinal cord infarction in children following cervical trauma, this article adds to the literature another case of a child with anterior spinal artery territory infarction due to rotatory atlantoaxial subluxation, leading to kinking and occlusion of vertebral artery, which highlights the difficulties and controversies in the management of this condition.

Large animal canine endovascular ischemic stroke models: A review.

Stroke is one of the leading causes of death and long-term disability worldwide. Recent exciting developments in the field with endovascular treatments have shown excellent outcomes in acute ischemic stroke. Prior to translating these treatments to human populations, a large-animal ischemic stroke model is needed. With the advent of new technologies in digital subtraction angiography, less invasive endovascular stroke models have been developed. Canines have gyrencephalic brain similar to human brain and accessible neurovascular anatomy for stroke model creation. Canine stroke model can be widely utilized to understand the disease process of stroke and to develop novel treatment. Less invasive endovascular internal carotid emboli injection and coil embolization methods can be used to simulate transient or permanent middle cerebral artery occlusion. Major restriction includes the extensive collateral circulation of canine cerebral arteries that can limit the stroke size. Transient internal carotid artery occlusion can decrease collateral circulation and increase stroke size to some degree. Additional method of manipulating the extent of collateral circulation needs to be studied. Other types of canine stroke models, including vertebral artery occlusion and basilar artery occlusion, can also be accomplished by endovascular thrombi injection. We extensively review the literature on endovascular technique of creating canine ischemic stroke models and their application in finding new therapies for ischemic stroke.

Bilateral vertebral artery occlusion without headache in giant cell arteritis

Giant cell arteritis (GCA) is well-recognized as an important cause of headache in the elderly.1 It is also an important element of the differential diagnosis for patients with transient or permanent visual loss. Delay in diagnosis of GCA can lead to blindness. Therefore, clinicians should be alert to atypical presentations in which headache is either not prominent or absent. We present a patient with GCA who had a cerebellar stroke and severe posterior circulation occlusive disease without headache.