Vertebrobasilar Insufficiency Research Articles

Variations in the Foramen Transversarium of Cervical Spine and Their Surgical Importance: An Osteological Study in Dried Cervical Vertebrae of North Indian Origin.

To examine the variations in number, size, and shape of foramina transversaria (FTs) of cervical vertebrae, and to discuss their clinical importance. The FTs of 200 dry cervical vertebrae (C3?C7) from 40 spines were studied for the presence of variations in their number (single, double, or triple), size, and shape. The foramina were classified according to their shape depending upon the direction of their main diameter. Accessory foramina were found in 40 cervical vertebrae. Bilateral accessory foramina were slightly more common than a unilateral accessory foramen. Accessory foramina occurred in a particular pattern, with incidence increasing with descending order of cervical vertebrae, and were most commonly found in C7. The mean values of the anteroposterior and transverse FT diameters on the right side were 4.96 ± 1.08 and 5.68 ± 1.20 mm, respectively, and on the left side were 5.07 ± 1.12 and 5.76 ± 1.29 mm, respectively. The difference was not statistically significant. FTs with very small diameter ( < 3.5 mm) were found mostly in C7 followed by C5 and C6. Five types of shape were noted. Type 1 was predominant on the right side, whereas type 4 was predominant on the left side. Differences in number (duplication), size, and shape of the FTs are not uncommon phenomena. Anatomical knowledge of FT variations is surgically pertinent, as in such conditions the vertebral artery may become twisted or deformed and result in vertebrobasilar insufficiency. Morphometric measurements from this study may be useful in interpreting radiographic images of the cervical spine obtained using computed tomography or cervical angiograms.

Using body tracking technology on the Habilect APC for the purpose of evaluation of the efficiency of physical rehabilitation of patients with vertebrobasilar insufficiency

Using body tracking technology on the Habilect APC for the purpose of evaluation of the efficiency of physical rehabilitation of patients with vertebrobasilar insufficiency

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.

Evaluation of shoulder stiffness due to vertebrobasilar insufficiency diagnosed from medical history and examination of the effectiveness of its treatment

Evaluation of shoulder stiffness due to vertebrobasilar insufficiency diagnosed from medical history and examination of the effectiveness of its treatment

Can Intracranial Vertebral Artery Hypoplasia be an Etiopathogenetic Factor for Barré-Ličou Syndrome Other than Arcuate Foramen? A Retrospective Clinical Study and Review of Literature.

To investigate the co-occurrence of the arcuate foramen (AF) variation of atlas and intracranial vertebral artery (V4) hypoplasia and, therefore, to understand the pathophysiology of Barré-Ličou syndrome (BLS). The AF localizes on the vertebral artery (VA) sulcus posterior to the atlas and has incomplete and complete types. Complete-type AF can exert pressure on the VA that passes through it, resulting in vertebrobasilar insufficiency finding, a BLS component. By the surgical decompression of VA at the AF level, complaints could be decreased in some cases. However, a reliable theory regarding BLS has not yet been established; therefore, the cases that do not respond to AF decompression have not been fully elucidated. We assumed that V4 hypoplasia that accompanies AF might be the main factor in the pathophysiology of BLS. Cervical computed tomography and magnetic resonance angiography images of 139 patients aged 14?88 years with head and neck pain and dizziness were retrospectively evaluated. Of the patients, 19.4% exhibited complete AF and 32.4% exhibited VA hypoplasia (VAH); 10% of the patients with VAH had accompanying contralateral complete AF variation. There was no significant relationship between complete AF and contralateral and ipsilateral VAHs (right side: p=0.527 and p=0.433, respectively; left side: p=1.000 and p=0.740, respectively). Our findings indicate that V4 hypoplasia is not the main factor of BLS pathophysiology. Furthermore, the rarity of the relationship suggests why some cases do not respond to decompressive surgery.

A case of recurrent loss of consciousness due to vertebrobasilar insufficiency during the initiation of dialysis

A case of recurrent loss of consciousness due to vertebrobasilar insufficiency during the initiation of dialysis

Rehabilitation features of patients with stroke in the vertebro-basillary system depending on the pathogenetic subtype of stroke

Ischemic stroke is a serious medical and social issue due to deep and prolonged disability, as well as social maladjustment of patients. In this regard, the aim of the research was to study the influence of pathogenetic subtypes of ischemic stroke on the rehabilitation possibilities.&#x0D; Based on the presence of COPD (Chronic Obstructive Pulmonary Disease) we divided all patients into 2 groups&#x0D; Patients with IS in VI (Vertebrobasilar Insufficiency) and COPD - 62 people (group I) - 29 men and 33 women aged 50 to 74 (59.8 ± 5.8). Patients with IS in VI - 64 people (group II). Of these, 31 are men and 33 are women aged 51 to 80 (62.4 ± 5.4). All patients received traditional treatment in the most acute and severe periods of IS, patients with COPD received and treatment for COPD simultaneously with traditional IS therapy. The Barthel index was used to assess the patient's self-care capabilities. The degree of disability after IS was studied using the Rankin scale. In patients of subgroup II b, by the end of the ED (Eating Disorders), the indicators of the Lindmark B scale for the patient's general mobility differed significantly from the baseline at the beginning of the ED (p = 0.44). At that time, in the II a subgroup, only the indicators of the B. Lindmark scale were reliable.&#x0D; In patients of subgroup II b, the difference in indicators at the beginning and at the end of ED was significant according to the Barthel index. Recovery in ED depends on many factors, including the subtype of IS, so the IS CE is the most severe, which is reflected in the Rankin scale. The timing and extent of patient recovery depends on the localization of the process, the subtype of IS, the presence of COPD, and the method of rehabilitation. Patients with the lacunar subtype, a single small or medium focus in the cerebellar hemispheres and midbrain recover most fully after complex rehabilitation.

Long-term outcomes of drug-eluting stent implantation in patients with symptomatic extra- and intracranial atherosclerotic stenoses.

ObjectiveImplantation of drug-eluting stents (DES) for extra- and intracranial atherosclerotic stenoses is an emerging topic. It has the potential benefit of preventing recurrent stroke with a reduced rate of in-stent restenosis (ISR).MethodsPatients who underwent extra- or intracranial stenting using DES in a single institution were retrospectively reviewed with long-term angiographic and clinical follow-up data.ResultsTwenty-one patients, 9 (42.9%) with extracranial lesions and 12 (57.1%) with intracranial lesions, were included. The most common symptom was cerebral infarction (71.4%), followed by vertebrobasilar insufficiency (19.1%) and transient ischemic attack (9.5%). All patients achieved technical success, with the mean degree of stenosis of 85.9±6.3% before the procedure and 19.5±5.9% after the procedure. All patients showed clinical improvement and no symptomatic recurrence was reported during the mean clinical follow-up period of 45.5±8.9 months. The significant ISR was observed in one patient (4.8%) during the mean radiological follow-up period of 42.8±10.0 months.ConclusionsImplantation of drug-eluting stents for symptomatic extra- and intracranial atherosclerotic stenoses is feasible and has the potential benefit of reducing the rate of ISR.

Evaluation on the application of transcranial Doppler (TCD) and electroencephalography (EEG) in patients with vertebrobasilar insufficiency

BackgroundTo evaluate the diagnostic value of transcranial Doppler (TCD) and electroencephalography (EEG) in patients with vertebrobasilar insufficiency (VBI) during clinical diagnosis and treatmentMethodsEighty patients diagnosed with VBI in our hospital from June 2018 to December 2019 were randomly selected as the observation group, and 80 healthy people who received physical examination in the same period were selected as the control group. The abnormal rate, main performance and results, and the peak velocity of blood flow and vertebrobasilar artery blood flow of the two groups were compared.ResultsThe abnormal rate of EEG and TCD in VBI patients was 38.75% (31/80) and the 93.75% (75/80), respectively. In TCD examination, ACA, PCA, MCA, and VA of both sides of the observation group were higher than those of the control group, while BA was lower than that of the control group (P < 0.05). The Vs, Vd, and Vm on both sides of BA and VA in the observation group were lower than those in the control group, while PI and RI were higher than those in the control group (P < 0.05).ConclusionsTCD examination is highly sensitive to the degree and pattern of cerebral ischemia in VBI patients. EEG examination will define the changes of brain cell function after cerebral ischemia. Therefore, EEG and TCD have their own advantages. The application of TCD and EEG can be considered in the early diagnosis, curative effect, and prognosis evaluation of VBI patients, so as to improve the accuracy of diagnosis and prognosis.

Vertebral Artery Loops and Cervicobrachial Pain

AbstractVertebral artery loop formation is an uncommon anatomical variation which may be asymptomatic or can cause cervicobrachial pain, radiculopathy, or even bone erosions and enlargement of neural foramina. As this entity is one of the uncommon causes of cervical radiculopathy, this report aims to create awareness among radiologists and clinicians, as vertebral artery loops may be seen incidentally in routine neuroimaging. magnetic resonance imaging (MRI) with magnetic resonance (MR) angiography or multislice computerized tomography (CT) angiography plays an important role in diagnosing as well as creating a roadmap for the surgery.Vertebral artery loop formation as a cause of radiculopathy is an uncommon condition. An abnormal course of vessel can lead to vascular injury during surgery, hence preoperative evaluation with CT or MRI is essential.1 2 Anomalous looping of vertebral artery can cause neurovascular compression apart from bony erosion, widening of vertebral foramen, and even vertebrobasilar insufficiency. Clinical features of vertebral artery loop formation can be radiculopathy, compression over cervical cord leading to sensory and motor deficit, and vertigo when associated with vertebra–basilar insufficiency, which is known as vascular vertigo. It has also been postulated that loop formation of vertebral artery can also lead to posterior circulation infarcts. Left vertebral artery is more prone for loop formation than the right vertebral artery, probably due to increased caliber in greater proportion of individuals. Multilevel and bilateral tortuosity can occur in younger patients rarely where imaging plays an important role.

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.

Subaxial Vertebral Artery Rotational Occlusion Syndrome: An Overview of Clinical Aspects, Diagnostic Work-Up, and Surgical Management.

Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.

Left Vertebral Artery to Common Carotid Artery Transposition in a Patient With Bilateral Vertebral Insufficiency: 3-Dimensional Operative Video

Extracranial vertebral artery (VA) atherosclerosis is responsible for 14% to 32% of posterior circulation infarctions.1 In the posterior circulation, narrowing of the VA>30% is significantly associated with strokes. Subclavian artery (SCA) atherosclerosis can produce subclavian steal. Retrograde VA flow around an occluded SCA decreases blood flow to the posterior circulation and causes vertebrobasilar insufficiency (VBI). Flow augmentation to the posterior circulation can be achieved by VA endarterectomy, arterial stenting, VA-common carotid artery (CCA) transposition, or bypass using an interposition graft.2,3 This video illustrates microsurgical revascularization of the proximal VA with VA-CCA transposition. A 58-yr-old man with a prior stroke and chronic right VA occlusion presented with dysarthria and gait instability. Angiographic evaluation confirmed complete midcervical right VA occlusion and left SCA occlusion proximal to VA origin, with subclavian steal. After obtaining patient consent and a failed attempt at endovascular recanalization of the left SCA, a left VA-CCA end-to-side transposition was performed. Neck dissection exposed the left CCA. The thyrocervical trunk served as a landmark to identify the SCA, which was traced proximally to the VA origin. After proximal occlusion, the VA was transected and "fish-mouthed" for end-to-side anastomosis to CCA. An intraluminal, continuous suture technique was used to sew the back walls of this anastomosis. Postoperative computed tomography angiography confirmed bypass patency. Collateral circulation through the thyrocervical and costocervical trunks likely supplied the left arm, and no cerebral, or limb, ischemic symptoms were noted on follow-up. VA-CCA transposition is an uncommon technique for safe and effective revascularization of symptomatic, medically refractory VBI caused by VA occlusion or, as in this case, SCA occlusion with secondary subclavian steal. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Improving the management of patients with a diagnosis of chronic cerebral ischemia

The diagnosis of сhronic cerebral ischemia is widely used in domestic neurological practice. A significant part of the patients observed with a diagnosis of сhronic cerebral ischemia suffer from primary or secondary headache, dizziness of various origins, emotional disorders and other diseases that are not diagnosed and therefore do not have effective treatment. Improving the management of patients with a diagnosis of сhronic cerebral ischemia requires the diagnosis and treatment of other diseases that are erroneously defined as сhronic cerebral ischemia. The observation data of 90 patients are analyzed, in which the identification of primary headaches (chronic migraine, chronic tension headache) and drug-induced headache allowed an adequate and effective combination treatment, including rational pharmacotherapy, educational conversations, cognitive-behavioral therapy sessions, relaxation classes and therapeutic exercises, with a pronounced positive effect. The results of a survey of 700 patients are discussed, in which the identification of the causes of dizziness (benign paroxysmal positional vertigo, Meniere’s disease, vestibular neuronitis, emotional disorders with instability) made it possible to carry out effective treatment, while most patients were observed for a long time with a diagnosis of chronic cerebral ischemia or vertebrobasilar insufficiency. In the management of patients with vascular cognitive impairment, which is the main clinical manifestation of chronic cerebrovascular disease, the leading role is given to both non-drug methods (regular physical activity, smoking cessation) and drug therapy aimed at normalizing blood pressure and blood lipid spectrum, preventing blood clots and improving cognitive function. The possibilities of naftidrofuril and nimodipine as drugs for improving cognitive function are discussed.

Posterior and lateral ponticles of atlas: An osteological study at Fatima Jinnah Medical University, Lahore

Background: Among the cervical vertebrae, atlas is known to have many variations, posterior ponticle being the commonest. It may completely or incompletely covers the groove of vertebral artery leading to ischemia of posterior circulation. Therefore, vertebral artery is at greater risk of injury during neurological and spinal surgeries. Prevalence of posterior ponticles varies widely among different populations, for instance in Turkish population it was 10.8%, in American 22.1%, Kenyan 14.7%, Brazilian and Indian 16.7%. The prevalence of lateral ponticle in Kenyan population was reported to be 3.9% and in Indians it was 2%. However, the data regarding the prevalence of these ponticles is largely lacking in Pakistan. Therefore, this research was designed to determine the prevalence of posterior and lateral ponticle in atlas vertebrae of Pakistani population.&#x0D; Materials and methods: A total of 47 human atlas vertebrae of unknown age and gender from bone bank of Department of Anatomy Fatima Jinnah Medical University, Lahore were studied for the presence of complete and incomplete posterior and lateral ponticles. The bones studied were completely intact and did not have any pathology.&#x0D; Results: Total incidence of ponticles was 38 % in this study, of which 36% were posterior ponticles and 2% were lateral ponticles. Bilateral incomplete posterior ponticles/were found in 8 (17%) atlas vertebrae whereas bilateral complete posterior ponticles/foramen arcuale were found in only 1 (2%) atlas vertebrae. Unilateral incomplete posterior ponticle was identified on right side in 5 (11%) and left side in 2 (4%) atlas vertebrae. Unilateral complete posterior ponticle was found in only 1 (2%) atlas on the left side whereas no such finding was identified on right side in any vertebra. Unilateral complete lateral ponticle was found in only 1 (2%) atlas on the right side but not on left side. No bilateral complete lateral ponticle and incomplete unilateral or bilateral lateral ponticles were identified in this study.&#x0D; Conclusion: Presence of posterior and lateral ponticles pose a risk of vertebrobasilar vascular insufficiency and may cause variety of symptoms. Vertebral artery may be at risk during neurosurgical procedures when having a foramen arculae and may give a false impression of much wider posterior arch of atlas. Knowing the prevalence of this can help neurosurgeons, general surgeons, radiologists, and chiropractors in management of the patients.

The Incidence of Central Neurological Disorders Among Patients With Isolated Dizziness and the Diagnostic Yield of Neuroimaging Studies.

Dizziness is a common symptom among emergency department (ED) patients and is often associated with benign processes. The aim of this study was to investigate the incidence of severe central neurological pathologies in isolated dizziness cases and the diagnostic efficiency of neuroimaging studies. All applications for isolated dizziness to an academic ED between January 1, 2011, and December 31, 2017 were retrospectively reviewed. The frequency of these admissions, the demographic data of the patients, the results of cranial computed tomography (CT) and diffusion-weighted magnetic resonance imaging (DW-MRI) studies, and the central neurological causes of isolated dizziness were recorded. The percentage of patients with isolated dizziness among all ED admissions was 2.5% (29,510/1,190,857). The median age of these patients was 52 years (interquartile range: 38 to 66) and 58% were female. During the study period, the rate of neuroimaging studies for isolated dizziness increased year by year, and a total of 6406 (21.7%) cranial CTs and 2896 (9.8%) DW-MRIs were performed. The diagnostic yield of neuroimaging studies was 0.6% for cranial CT and 3.9% for DW-MRI. Central neurological disorders were detected in 143 (0.48%) patients with isolated dizziness. The most common causes were posterior circulation ischemic strokes (47.5%), other ischemic strokes (18.9%), vertebrobasilar insufficiency (10.5%), and transient ischemic attack (8.4%). Isolated dizziness is rarely associated with central neurological pathologies. Neuroimaging studies, especially cranial CT, have low diagnostic yield in isolated dizziness and should therefore not be routine in the evaluation process.

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.

FIVE CASES OF ACUTE HYPOACUSIA/DEAFNESS SECONDARY TO ARTERIAL AND VENOUS CEREBROVASCULAR DISEASE

I present five cases of acute onset hypoacusia (four unilateral and one bilateral), all of different physiopathological mechanisms and vascular territories, secondary to either arterial or venous causes. First case is a 39-year-old male with Left Middle Inferior Pontine Syndrome (Foville Syndrome) with associated Vertebro-Basilar Insufficiency (VBI) secondary to Spontaneous Vertebral Artery Dissection (SVAD) and secondary hypoacusia. Case two, is a 76-year-old female with right Anterior Inferior Cerebellar Artery (AICA) Syndrome generating a lateral pontine infarct with hypoacusia as an initial presentation. Case three, is a 77-year-old male presenting a left Superior Cerebellar Artery (SCA) infarct with hypoacusia as an initial presentation. Case four, a 79-year-old female patient presenting sudden onset bilateral hypoacusia secondary to Basilar Artery (BA) thrombosis. Finally, case five, is a 23-year-old post-partum female presenting a right Transverse Venous Sinus Thrombosis (CVST) presenting with acute hypoacusia as only clinical manifestation. Keywords: hypoacusia, deafness, cerebrovascular disease.

Does thoracic outlet syndrome cause cerebrovascular hyperperfusion? Diagnostic markers for occult craniovascular congestion

Thoracic outlet syndrome (TOS) is known to be associated with diffuse craniological comorbidities (CCM), such as occipital headaches, migraines, vestibular dysfunction, tinnitus and fatigue. Conventionally, these problems have been suggested to be a manifestation of positional vertebrobasilar insufficiency. Angiography tends to be normal in TOS sufferers, however, and doppler ultrasonography of the vertebral artery fails to demonstrate severe flow reduction. TOS is attributed to the brachial plexus and subclavian artery being compressed in the interscalene triangle, costoclavicular or subpectoral passages. The vertebral and carotid arteries arise from subclavian artery proximal to the sites of obstruction in TOS. Numerous reports of resolved CCM post-scalenectomy and first-rib resection, despite lacking vertebral artery impairment, have been documented. TOS CCM, moreover, share many of the symptoms seen in systemic and intracranial hypertension. Reports of subclavian thromboembolus migrating to the head have been documented in incidences of TOS, showing the potential for flow retrogradation. We postulate that the blood prevented from entering the brachium due to distal subclavian compression, retrogrades to the brain via the carotid and vertebral arteries, resulting in craniovascular hyperperfusion and congestion. &#x0D; Abbreviations: Thoracic outlet syndrome: TOS, Vertebral artery: VA, Vertebrobasilar insufficiency: VBI, Cerebrovascular hyperperfusion: CVH, Blood-brain barrier: BBB, Myalgic encephalomyelitis: ME, “Time of flight”: TOF,&#x0D; Citation: Larsen K, Galluccio FC, Chand SK. Does thoracic outlet syndrome cause cerebrovascular hyperperfusion? Diagnostic markers for occult craniovascular congestion. Anaesth pain intensive care 2020;24(1)___&#x0D; Received – 30 November 2019;&#x0D; Reviewed – 2, 6 February 2019;&#x0D; Accepted – 27 February 2019;

Safety and durability of concomitant carotid endarterectomy with carotid-subclavian bypass grafting

BackgroundConcomitant carotid endarterectomy (CEA; for severe internal carotid artery stenosis) with carotid-subclavian bypass grafting (CSBG; for proximal common carotid artery or subclavian artery occlusion) is rarely used. Only a few studies have been reported. This report analyzed early and late clinical outcomes of the largest study to date of the combined procedures in our institution. MethodsElectronic medical records of patients who had concomitant CEA with CSBG during three decades were analyzed. Indications for surgery were arm ischemia, neurologic events, and clinical subclavian steal. Early (30 days) perioperative complications (stroke, death, and others) and late complications (stroke, death) were recorded. Kaplan-Meier analysis was used to estimate late graft/CEA primary patency, freedom from stroke, and stroke-free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound. Outcomes were compared with previously published data on isolated CSBG by the same group. ResultsThere were 37 combined procedures analyzed. Mean age was 64 years (range, 45-81 years). Indications for surgery were arm ischemia in 12 (32%), hemispheric transient ischemic attack or stroke in 15 (41%), vertebrobasilar insufficiency in 4 (11%), symptomatic subclavian steal in 10 (27%), and asymptomatic common carotid artery occlusion with severe internal carotid artery stenosis in 6 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100%, with 2.7% (transient ischemic attack) symptom recurrence. The crude patency rate of both CEA and CSBG was 92%. At 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, primary patency rates were 100%, 96%, 96%, 96%, and 85%; freedom from stroke rates were 97%, 97%, 97%, 97%, and 97%; and stroke-free survival rates were 94%, 94%, 87%, 82%, and 78%. When these outcomes were compared with the isolated CSBG group alone (28 patients), there was no difference in perioperative stroke (2.7% for concomitant CEA/CSBG vs 0% for isolated CSBG), perioperative death (2.7% vs 2.8%), or late patency rates (92% vs 96%). ConclusionsConcomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG.