Vertebral Artery Occlusion Research Articles

Favorable Long-Term Outcomes for Positional Vertebral Artery Occlusion with Treatment Strategy Prioritizing Spinal Fusion Surgery.

Positional vertebral artery occlusion (PVAO) has a fundamental problem in the definition. We analyzed the long-term outcomes with a redefinition of the rare clinical entities as PVAO for a broader conceptualization, and discuss the efficacy of fusion surgery as a treatment option. We analyzed the clinical and radiologic characteristics and outcomes in 8 patients with PVAO who experienced cerebral ischemia during a 10-year period at our institution. The follow-up periods ranged from 60 to 132 months (mean, 93.5 months). All patients were initially treated conservatively with external fixation. If spinal instability was observed at the initial evaluation or a second stroke occurred during conservative treatment, cervical spinal fusion was performed with special consideration for vertebral artery dominance and the presence of its collateral flow regardless of the type of stroke. Conservative therapy was completed for 2 patients, and spinal fusion was performed for the other 6 patients. None of the patients experienced a recurrence of symptoms after discharge until the final follow-up visit, and the outcomes were excellent. Long-term functional outcomes were dependent on the patient's condition before the onset of stroke and the neurologic deficits resulting from the initial or recurrent stroke induced by embolism. We report our single-center experience with PVAO in which 75% of patients had embolic stroke. Because embolic stroke may have a greater risk of recurrence affecting the long-term outcomes, it should be prevented. In addition, if surgical intervention is necessary, spinal fusion surgery may be an effective option.

Awareness of traumatic occult lateral mass fracture of the cervical spine triggered by the presence of unilateral vertebral artery occlusion: a case report.

We present an unusual case of traumatic occult lateral mass fracture of the cervical spine with unilateral occlusion of the vertebral artery (VA), that was missed by plain X-ray and magnetic resonance imaging (MRI), but identified by computed tomography (CT) after suspecting high-energy trauma as the underlying cause. A 67-year-old male was injured in a car accident and came to our institute on foot 4 days after injury with complaints of neck pain and numbness in the right hand. Although, no specific bone injury was visible on plain X-ray, the absence of flow voids in the right VA was confirmed on axial T2-weighted MRI. We suspected high-energy trauma of the cervical spine at that point and performed CT for a more detailed assessment. Consequently, a fracture was detected in the right lateral mass of C6 and we speculated that spontaneous reduction of the fracture-dislocation had occurred. One-stage surgery with posterior fixation was subsequently performed for instability. The patient's preoperative symptoms were improved and neither recanalization of the occlusion nor another VA occlusion was observed after surgery. VA injury occurs frequently as a complication of blunt cervical spine trauma. In the present case, however, the lateral mass fracture was not seen on MRI and missed until the unilateral VA injury was detected. When high-energy trauma of the cervical spine is suspected, it is important to evaluate damage to the spinal cord, bone, soft-tissue, and VA by MRI and CT.

Two-stage corrective surgery for severe rigid cervical kyphotic deformity with unilateral vertebral artery occlusion after old blunt trauma: a case report.

There are considerable risks for vertebral artery (VA) injury in case of corrective surgery for a severe and rigid cervical kyphotic deformity. This case report describes a rare case of surgical management for pre-existing traumatic rigid cervical kyphosis associated with unilateral VA occlusion. A 73-year-old male fell down and injured his neck. He was referred to our hospital 10 months after injury because his degree of head drop progressed gradually to a chin-on-chest position such that he could not look straight forward. On plain X-ray, the C2-7 angles in the neutral, flexion, and extension positions were 61°, 71°, and 50°, respectively. CT revealed a collapse of the C5 vertebral body and bone fusion between C4 and C5 in the anterior vertebrae, and unilateral VA occlusion was confirmed by angiography. Two-stage surgery was planned to correct the kyphosis. In the first stage, anterior release of the C4/5 bone-spur fusion and dissection of the intervertebral disk were performed. After release, angiography confirmed neither occlusion nor rupture of the VA. In the second stage, anterior and posterior fixation was performed at correcting position while maintaining slight kyphosis in order to avoid excessive distortion of the VA. The postoperative C2-7 kyphosis angle improved to 16° without any VA injury, and the patient could look forward easily. The degree of correction as well as risk management of VAs should be considered carefully during corrective surgery for severe and rigid cervical kyphosis, especially with unilateral VA occlusion.

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.

Endovascular recanalization for chronic symptomatic intracranial vertebral artery total occlusion: Experience of a single center and review of literature

ObjectiveThe optimal treatment of chronic symptomatic total occlusion of the intracranial vertebral artery (ICVA) remains undefined. We report a single-center experience of endovascular recanalization for patients with chronic symptomatic ICVA occlusion who were refractory to medical therapy. MethodsFrom Jan 2009 to Jan 2017, we retrospectively reviewed 14 consecutive patients presenting with recurrent symptoms attributed to the chronic ICVA occlusion. We searched previous literature using PubMed databases during the same period as comparison. ResultsEleven patients out of 14 presented initial symptoms to intervention less than 90days. The occlusion course was extrapolated on simultaneous two-vessel injection angiography or high-resolution MR imaging (HRMRI) in 13 cases. Nine patients had the occlusion beyond the origin of posterior inferior cerebellar artery (PICA) and 5 had the occlusion proximal to the PICA origin. The technical success rate of recanalization was 85.7% (12/14). Two patients (14.3%, 2/14) had peri-procedural complications: 1 developed TIA and 1 presented with perforator occlusion syndrome. Using the keyword-based search, we identified 6 studies at the same period. A total of 34 patients underwent recanalization with the successful recanalization rate at 94.1%, peri-procedural complication rate at 17.6% and mortality at 2.9%, respectively. ConclusionOur single-center study illustrated the feasibility and safety of ICVA recanalization. Great care should be taken as revascularization is of high risk. When patient selection, occlusion course and stage as well as neuroimaging evaluation are considered, endovascular recanalization may be a useful therapeutic modality.

Giant Vertebrobasilar Dissection Aneurysm and Dolichoectasia Bypass Treatment

Objective Giant vertebrobasilar artery dissection aneurysm as well as VBD patients (vertebrobasilar dolichoectasia, VBD) have poor prognosis even under interventional therapy and conventional neurosurgical operation. There are two concepts to deal with it: direct basilar tip bypass with vertebral artery and basilar artery occlusion simultaneously or bypass to provide flow to basilar artery tip combined with flow reduction. Retrospectively analyze operative results under different concept for giant basilar artery aneurysm as well as VBD patients.

Abstract WP121: One-Year Risk of Recurrent Stroke Associated With Vertebral and Basilar Artery Stenosis and Occlusion in a Cohort of 10,515 Ischemic Stroke Patients

Background: The risk of recurrent stroke in patients with ischemic stroke with vertebral/basilar artery stenosis remains to be systematically studied. Methods: We analyzed data from Taiwan Stroke Registry (TSR), with stroke registries provided by 59 hospitals. Patients who had diagnosis of ischemic stroke and were categorized into the “large artery atherosclerosis” group by TOAST who underwent CTA, MRA, or catheter- based angiography were identified for the present study. The patients were divided into 3 groups based on the extent of vertebral (VA) and/or basilar artery (BA) stenosis as follows: 0-49%, 50-99%, and 100% (total occlusion). Cox proportional hazards model was used to determine the hazard ratios (HRs) of recurrent stroke within 1 year of index event after adjusting for all relevant risk factors by univariable Cox model. Results: In the TSR data base, 84,831patients were in the ischemic stroke group. Based on TOAST, 20,220 patients were in the large-artery atherosclerosis group. Among these patients, a total of 10,515 were of age 18 or greater who had CTA, MRA or angiographic studies that included VA/BA. There were 6,972 subjects with VA/BA stenosis in the 0-49%, 3,137 in the 50-99% and 406 in the 100% (total occlusion) groups respectively. With VA/BA stenosis in the 0-49% range as the reference, HRs of recurrent stroke in one year by multivariable modeling with adjustment of all relevant risk factors by univariable Cox model was 1. 29 (95% CI, 1.05 - 1.58, p<0.05) in the 50-99% and 1.64 (95% CI, 1.07 - 2.52, p<0.05) in the 100 % group with P trend < 0.02, denoting that a greater extent of VA/BA stenosis was associated with a relatively greater risk of recurrent stroke in 1 year after stroke. Conclusions: Vertebral or basilar artery stenosis or occlusion was relatively prevalent among patients with ischemic stroke categorized in the large artery artherosclerosis group by TOAST with greater extent of VA/BA stenosis carrying greater risk of recurrent stroke within 1 year after stroke.

Abstract WP387: Diagnosis and Surgical Management of Rotational Vertebral Artery Occlusion in Children

Background: Rotational vertebral artery occlusion (RVAO) is associated with significant posterior circulation morbidity, recurrence, and lacks evidenced based treatment recommendations. Upper cervical spine abnormalities, lack of traumatic history, and dynamic vessel imaging aid in diagnosis and treatment options. Here, we evaluate our cohort of children with RVAO for associated musculoskeletal, angiographic, and arterial tortuosity factors in light of management strategies and outcomes. Methods: Five pediatric patients with RVAO were evaluated with dynamic arterial compression with either CT based angiography or digital subtraction angiography. Solitary factors such as ponticulous posticus, hypermobility comorbidities, 3D-print models and arterial tortuosity index were examined in relation to management strategies. Results: Musculoskeletal abnormalities were associated in all cases presenting with evidence of dynamic angiographic compression. Not all cases had evidence angiographic compression. A mild elevation in arterial tortuosity index was observed. All five patients were managed with treatment approaches including antiplatelet/coagulation therapies, vertebral artery decompression, and/or posterior cervical fusion. Conclusion: Treatment strategies relied on identifiable compression factors associated with the level of vertebral artery dissection. In children, upper cervical bony abnormalities and dynamic compression at the VA3 level are common to RVAO diagnosis. Further examination of arterial tortuosity as an index in understanding the susceptibility of children towards RVAO is required.

Predictors for Intracranial Hemorrhage Following Intravenous Thrombolysis in Posterior Circulation Stroke.

Intravenous thrombolysis (IVT) is a standard treatment for anterior (ACS) and posterior circulation stroke (PCS). However, due to the low occurrence of PCS and of intracranial hemorrhage (ICH) in PCS, the knowledge about ICH predictors following IVT in PCS is sparse. Our aim was to identify predictors for ICH following IVT in PCS. The set consisted of 1281 consecutive ischemic stroke (IS) patients treated with IVT, out of which 158 (103 males; mean age 65.6 ± 12.3years) had PCS. Collected data include baseline characteristics, common stroke risk factors, pre-medication, stroke severity, admission blood glucose level, blood pressure and treatment with intravenous antihypertensive therapy before and during IVT, occlusion of arteries, recanalization rate, time to treatment, and clinical outcome at day 90. Overall, 11 (7%) patients had ICH. Atrial fibrillation (p = 0.004), neurological deficit at time of treatment in the National Institutes of Health Stroke Scale (p = 0.016), decreased level of consciousness (p = 0.003), occlusion of basilar artery (p = 0.007), occlusion of PCA (p = 0.001), and additional endovascular therapy (p = 0.001) were identified by logistic regression analysis as significant predictors for ICH in PCS. Patients with ischemic lesion in the brainstem, occlusion of vertebral artery, or absence of basilar and posterior cerebral artery occlusion might be considered for treatment with IVT even in borderline cases. Those patients seem to have less frequently favorable outcomes without an increase in ICH rate. Time to IVT in PCS seems not to influence ICH risk or chances for favorable outcomes as significantly as it does in ACS.

The role of argon in stroke

Stroke, also known as “cerebrovascular accident”, is an acute cerebrovascular disease that is caused by a sudden rupture of blood vessels in the brain or obstruction of the blood supply by blockage of blood vessels, thus including hemorrhagic and ischemic strokes. The incidence of ischemic stroke is higher than that of hemorrhagic stroke, and accounts for 80% of the total number of strokes. However, the mortality rate of hemorrhagic stroke is relatively high. Internal carotid artery and vertebral artery occlusion and stenosis can cause ischemic stroke, and especially males over 40 years of age are at a high risk of morbidity. According to the survey, stroke in urban and rural areas has become the first cause of death in China. It is also the leading cause of disability in Chinese adults. In a word, stroke is characterized by high morbidity, high mortality and high disability rates. Studies have shown that many noble gases have the neuroprotective effects. For example, xenon has been extensively studied in various animal models of neurological injury including stroke, hypoxic-ischemic encephalopathy. Compared to xenon, Argon, as a noble gas, is abundant, cheap and widely applicable, and has been also demonstrated to be neuroprotective in many research studies. In a variety of models, ranging from oxygen-glucose deprivation in cell culture to complex models of mid-cerebral artery occlusion, subarachnoid hemorrhage or retinal ischemia-reperfusion injury in animals. Argon administration after individual injury demonstrated favorable effects, particularly increased cell survival and even improved neuronal function. Therefore the neuroprotective effects of argon may be of possible clinical use for opening a potential therapeutic window in stroke. It is important to illuminate the mechanisms of argon in nerve function and to explore the best use of this gas in stroke treatment.

Successful Treatment of Sudden Bilateral Sensorineural Hearing Loss due to Atherosclerotic Vertebral Artery Occlusion: A Case Report

Successful Treatment of Sudden Bilateral Sensorineural Hearing Loss due to Atherosclerotic Vertebral Artery Occlusion: A Case Report

Incidence of Traumatically Induced Vertebral Artery Occlusion Associated with Cervical Spine Injuries: Prospective Study Using Magnetic Resonance Angiography

Incidence of Traumatically Induced Vertebral Artery Occlusion Associated with Cervical Spine Injuries: Prospective Study Using Magnetic Resonance Angiography

Carotid angioplasty and stenting in a patient with high grade stenosis of Internal Carotid Artery associated with both vertebral arteries and contralateral carotid occlusion

Severe internal carotid artery (ICA) stenosis is a common cause of cerebrovascular accident (CVA) in middle-aged patients. Contralateral carotid occlusion (CCO) in patients with severe ICA stenosis is associated with high risk of CVA. Carotid endarterectomy (CEA) is associated with more complications in patients with CCO than those without CCO. In this study, we present the case of a 61-year-old patient who presented with multiple transient ischemic attack and severe ICA stenosis associated with CCO and occlusion of vertebral arteries. The patient was treated successfully with carotid angioplasty and stenting.

A new endovascular treatment of a recurrent giant proximal basilar aneurysm after coiling

BackgroundTreatment of giant basilar aneurysms is extremely challenging, especially recurrences after previous coiling.Case presentationA 20-year-old male was referred for a recurrent giant proximal basilar aneurysm 3 months after coiling, with headache, blurred vision, and brainstem compression symptoms. Angiography showed that the previously placed coils were compacted within the caudal portion of the 43 mm × 31 mm aneurysm, with spontaneous occlusion of the right vertebral artery and absence of the posterior communicating arteries. The diameter of the aneurismal neck, the afferent and efferent arteries was 6 mm, 3.5 mm and 4.1 mm, respectively. A balloon-expandable covered-stent of 3.5 mm × 10 mm was selected, matching the above 3 measurements; and deployed precisely across the aneurismal neck, immediately creating the “sub-complete reconstruction with intentional endoleak distal to aneurismal neck”. Subsequently, 2 self-expanding 4.5 mm × 37 mm stents were telescopically implanted within the covered-stent to adjust the angulation of the proximal basilar artery. After the procedure, the patient’s symptoms gradually disappeared. Catheter angiography at 18 days, 3 months and 15 months demonstrated complete aneurismal exclusion from the patent vertebrobasilar artery, with dramatic elimination of aneurismal volume and reconfiguration of the compacted coils. The patient was asymptomatic at 15-month follow-up.ConclusionsSub-complete reconstruction with intentional endoleak distal to aneurismal neck can be safely achieved after implantation of a covered-stent and conventional stents in the case of a recurrent post-coiling proximal giant basilar aneurysm, with complete vascular reconstruction subsequently.

A Case of Medullary Infarction Presented Initial Symptoms Similar to Meniere's Disease.

Fluctuating hearing loss and vertigo are the typical presentations of Meniere’s disease. However, it is unusual that fluctuating hearing loss and vertigo are caused by vertebral artery occlusion or cerebral infarction. Here, we described the case of a 54-year-old male patient with hypertension and diabetes mellitus who presented with fluctuating hearing loss in his left ear and severe whirling-type dizziness without associated neurological signs or symptoms. Temporal magnetic resonance imaging (MRI) was normal. He was diagnosed with a possible Meniere’s disease and started conservative treatment. Eight years later, the patient developed dysarthria and left-side weakness. Brain MRI revealed right anterior medullary infarction, and cerebral angiography showed occlusion of the right vertebral artery. In this case, we attempted to review the initial imaging study and reported the characteristics of the case.

Stent-assisted coiling of a ruptured vertebrobasilar junction aneurysm via direct vertebral artery puncture

A 78-year-old patient was admitted with subarachnoid hemorrhage caused by rupture of a broad-based vertebrobasilar junction aneurysm. Direct endovascular access to the vertebrobasilar circulation was not possible due to chronic...

Clinical significance of reversal of flow in the vertebral artery identified on cerebrovascular duplex ultrasound

BackgroundReversal of flow in the vertebral artery (RFVA) is an uncommon finding on cerebrovascular duplex ultrasound examination. The clinical significance of RFVA and the natural history of patients presenting with it are poorly understood. Our objective was to better characterize the symptoms and outcomes of patients presenting with RFVA. MethodsA retrospective review was performed of all cerebrovascular duplex ultrasound studies performed at our institution between January 2010 and January 2016 (N = 2927 patients). Individuals with RFVA in one or both vertebral arteries were included in the analysis. ResultsSeventy-four patients (74/2927 patients [2.5%]) with RFVA were identified. Half of the patients were male. Mean age at the time of the first ultrasound study demonstrating RFVA was 71 years (range, 27-92 years); 78% of patients had hypertension, 28% were diabetic, and 66% were current or former smokers. Indications for the ultrasound examination were as follows: 44% screening/asymptomatic, 7% anterior circulation symptoms, 20% posterior circulation symptoms, 28% follow-up studies after cerebrovascular intervention, and 5% upper extremity symptoms. At the time of the initial ultrasound examination, 21 patients (28%) had evidence of a prior carotid intervention (carotid endarterectomy or carotid stenting), 21 patients had evidence of moderate (50%-79%) carotid artery stenosis (CAS) in at least one carotid artery, and 12 patients (16%) had evidence of severe (>80%) CAS. Of the 15 patients presenting with posterior circulation symptoms, 11 (73%) had evidence of concomitant CAS. In contrast, 22 of the 59 patients (37%) without posterior circulation symptoms had duplex ultrasound findings of CAS (P = .01). The mean duration of follow-up was 28 ± 22 months. Follow-up data were available for 63 patients (85%), including the 15 patients who presented with posterior circulation symptoms. Of these 15 patients, 5 underwent subclavian artery revascularization, including balloon angioplasty and stenting in 4 patients and open/hybrid revascularization in 1 patient. Five individuals were awaiting intervention. Three patients underwent carotid endarterectomy for CAS, with resultant improvement in posterior circulation symptoms. Finally, one patient was deemed too high risk for intervention, and one patient was found to have an alternative cause for symptoms. The remaining 59 patients continued to be asymptomatic during follow-up. One patient progressed to vertebral artery occlusion, and six patients had progression of CAS. ConclusionsSymptomatic RFVA responds well to intervention, including subclavian artery stenting and carotid intervention in patients with CAS. The majority of patients with this finding are asymptomatic at the time of presentation. Although progression of vertebral artery disease is rare, these patients may benefit from monitoring for progression of CAS with surveillance ultrasound.

Poster 338: Brown-Sequard Syndrome due to Ischemia from a Vertebral Artery Occlusion: A Case Report

Poster 338: Brown-Sequard Syndrome due to Ischemia from a Vertebral Artery Occlusion: A Case Report

Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion

Objective: The aim of this study was to evaluate the feasibility and safety of multimodal therapy for patients with non-superacute vertebral basilar artery occlusion. Method: We performed a retrospective analysis of multimodal therapy for patients with vertebral basilar artery occlusion. All patients who were beyond the time window to receive intravenous thrombolysis and who had deterioration of symptoms after drug treatment received small-balloon dilatation of the occlusive artery to estimate vascular occlusion aetiology. Thrombectomy with a Solitaire AB system was applied to the thrombus, and angioplasty with intracranial stents was used to treat stenosis. During the 3-month follow-up, National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores were recorded regularly. Results: We included 12 patients with a mean age of 60.4 (SD: 12.9) years. The average score on the NIHSS was 16.6 (SD: 11.6), and the average time from onset to admission was 95 h (SD: 121). The arteries were recanalized for all patients, but the degree of residual stenosis in the parent artery was 17.5% (SD: 20.1). During the follow-up period, one patient died of pulmonary haemorrhage and infection, and another patient died from haemorrhage related to high perfusion. After 3 months of follow-up, the 10 surviving patients showed an average NIHSS score of 7.9 (SD: 8.7) and an average mRS score below 2 (1.3 ± 1.4). Conclusion: For patients with posterior circulation stroke due to basilar artery or vertebral artery occlusion who present to the hospital 6 h after symptom onset and who exhibit deterioration of symptoms after drug treatment, multimodal recanalization of the occluded artery may be a feasible and safe therapy.

Early recanalization of acute occluded vertebral artery dissecting aneurysm after subarachnoid hemorrhage: two cases

Early recanalization of acute occluded vertebral artery dissecting aneurysm after subarachnoid hemorrhage: two cases