Anastomosis of the superior thyroid artery to the vertebral artery for vertebrobasilar insufficiency

Anastomosis of the superior thyroid artery to the cervical vertebral artery was performed with good results in a case of vertebrobasilar insufficiency caused by proximal occlusion of the vertebral artery. As a donor artery the superior thyroid artery is moderate in size, long, and easy to anastomose. It is emphasized that this cervical procedure is simpler and safer than the intracranial procedures. The authors believe this case to be the first in which the superior thyroid artery was used as a donor artery for anastomosis to the vertebral artery.     

Extracranial vertebral artery dissection repeating distal embolism: case report

We report a case of vertebral artery (VA) dissection presenting with repeated distal embolism. A 48-year-old man was admitted to our institution with neck pain and vertigo of two day duration. MRI on arrival showed infarction of the left cerebellar hemisphere and the right occipital lobe. Emergency angiography revealed left VA dissection and occlusion of the left posterior inferior cerebellar artery and right calcaline artery. Six hours after admission, he manifested cortical blindness due to embolism of the contralateral left calcaline artery despite giving heparin and aspirin. Thrombolysis was performed but was not successful. We embolized the affected VA to prevent further embolism. We discuss here the indication and timing of treatment for VA dissection presenting with ischemic symptom.     

Carotid to distal vertebral artery bypass for vertebrobasilar ischemia. Case report

A simple technique is described for a venous graft between the common carotid artery and the extracranial vertebral artery. In the case described, the vertebral artery was shown angiographically to be occluded and reconstituted by collateral vessels. This patient had symptoms of vertebrobasilar insufficiency which resolved postoperatively.     

Vertebral artery occlusion at the narrowed "scalenovertebral angle": mechanical vertebral occlusion in the distal first portion

We report a patient who developed occasional vertigo when turning his head to the right side. Occlusion of the right vertebral artery occurred at the narrowed "scalenovertebral angle" with this rotational head movement. This triangular tunnel consisted of the hypertrophied ligament of the longus colli muscle and the anterior scalene muscle. Decompression of these extraluminal compressive factors led to relief of the symptoms. Two different kinds of extrinsic compression at the first portion of the vertebral artery are discussed.     

Reconstruction of vertebral artery stenosis.

Eight patients with transient attacks of cerebrovascular insufficiency were treated by reconstruction of an atheromatious stenosis at the origin of a vertebral artery. The technique was relatively simple and safe, and was effective in relieving symptoms. Previous reviews suggest that the symptoms of vertebrobasilar insufficiency tend to be persistent, frequent and distressing, and that they can be a prelude to brain stem infarction. The collateral circulation to the vertebrobasilar system may be restricted by anatomical variations and by disease, particularly affecting the circle of Willis. Bilateral vertebral artery disease can cause appreciable ischaemia even without associated carotid artery disease. Carotid endarterectomy is not particularly effective in relieving vertebrobasilar symptoms. Vertebral artery reconstruction appears to be the appropriate treatment for vertebrobasilar insufficiency.     

"Stretched loop sign" of the vertebral artery: a predictor of vertebrobasilar insufficiency in atlantoaxial dislocation

BACKGROUND: Vertebrobasilar territory infarction is one of the rarer presentations of CVJ anomalies. A new radiologic sign due to stretching of the short third segment of VA detected on MRA/DSA may identify patients of AAD at risk of developing VBI. METHODS: Seven patients who presented with VBI were found to have a coexisting mobile (n = 6) or fixed (n = 1) AAD. None of these patients had the presence of any of the known risk factors for cerebrovascular disease. On identification of VBI on CT/MRI, DSA (n = 7) and MRA (n = 1) were performed to assess bilateral vertebral arteries. The course of normal VA was also studied in 5 control patients without AAD or VBI. RESULTS: Digital subtraction angiography/MRA showed obstruction of VA at the C1 through C2 level on one side in each of these cases. The third segment of the contralateral VA showed a shortened and straighter loop termed as the stretched loop sign of the VA. On DSA, the latter manifested as (a) opening of the distal loop of the VA as it emerges from the foramen transversarium of the atlas and traverses on the dorsum of the posterior arch of atlas (n = 3), (b) shortened and stretched VA that runs laterally and posteriorly forming the proximal loop after emerging from the foramen transversarium of the axis (n = 2), or (c) both (n = 2). All patients presented with the clinical manifestations of VBI. Only 2 of these had preexisting myelopathy and long tract signs conventionally attributable to AAD. CONCLUSION: Vertebrobasilar territory infarction in AAD may occur because of the obstruction of the third segment of VA. A shorter and straighter loop of the third segment of VA coexisting with an abnormal translational mobility between the atlas and the axis may be the etiopathogenetic factor.     

Suboccipital approach to the distal vertebral artery.

A technique to expose directly the pars atlantica or the vertebral artery through a posterior approach was studied. It is useful when dealing with occlusive, aneurysmal, or dissecting lesions that extend to the transverse process of C1 or beyond. This technique permits exposure of the entire pars atlantica or the vertebral artery, from its exit from the foramen transversarium of C1 to its penetration of the dura mater at the foramen magnum. The experience with this technique in three patients is described.     

Extracranial vertebral artery stent placement: in-hospital and follow-up results.

OBJECT: The authors summarize their experience with stent deployment in the treatment of vertebrobasilar artery (VBA) insufficiency. This is an underdiagnosed condition, and the incidence of significant vertebral artery (VA) stenosis has been underappreciated. Medical therapy has been the mainstay of treatment because of the high rate of morbidity associated with surgical correction of VA stenosis. Recently, some authors have reported acceptable results with the use of percutaneous transluminal angioplasty, but this technique has significant weaknesses such as elastic recoil and problems in achieving safe treatment of dissections. METHODS: The authors investigated the feasibility, safety, and outcome of VA stent placement in 50 patients in whom 55 vessels were treated using stents. Technical success was achieved in 54 (98%) of 55 vessels, with no procedure-related complications. However, one patient (2%) died of nonneurological causes, and one (2%) suffered a stroke that occurred within the 30-day postprocedural period and was related to a complicated coronary intervention. Clinical follow-up review performed at a mean of 25 +/- 10 months revealed two patients (4%) with recurrence of VBA symptoms. Six-month angiographic follow up was completed in 90% of eligible patients, with a 10% incidence of restenosis as defined by greater than 50% luminal narrowing. CONCLUSIONS: Vertebral artery stent placement is feasible in patients who have significant VA stenosis, with predictably good angiographically demonstrated and clinical results. The 6-month angiographically confirmed restenosis rate appears to be low, as does the clinical recurrence rate. This technique solves the problems of elastic recoil and the treatment of angioplasty-induced dissections. Further prospective comparison with medical preventive strategies is warranted.     

Embolic lesions from the subclavian artery causing transient vertebrobasilar insufficiency

Thirteen patients with transient vertebrobasilar insufficiency caused by emboli from a proximal subclavian artery lesion were treated over a 5-year period. This group was characterized by the absence of significant carotid disease (12 of 13 patients) and equal arm pressures bilaterally in most patients (8 of 13 patients). An isolated supraclavicular bruit (12 of 13 patients) and a history of ipsilateral digital ischemia (5 of 13 patients) were common. Arch angiography demonstrated proximal subclavian lesions in 12 patients, with obvious ulcerations in 10 cases and thrombus in an old carotid-subclavian bypass graft in one case. Surgery directed at removal or exclusion of the lesion was successful in all cases. Isolated lesions in the subclavian artery can be a source of emboli into the vertebrobasilar circulation. These lesions are effectively treated by exclusion and vascular reconstruction.     

Reconstruction of distal foot wounds with reverse first dorsal metatarsal artery flap

Reconstruction of the distal portion of the foot has always represented a difficult problem in plastic surgery. We report a distally based dorsalis pedis island flap based on the first dorsal metatarsal artery, which has been successfully used to treat the distal portion of the foot in eight patients. The size of flaps ranged from 3 cm × 4 cm to 6 cm × 7 cm. In seven patients, the transferred flaps survived completely and in one flap there was superficial marginal necrosis. There was no donor site morbidity. All the patients had no difficulty in wearing shoes and were walking within 6 weeks. We suggest that the reverse first dorsal metatarsal artery flaps is a good option to reconstruct the wound of distal foot.     

Vein graft replacement of the distal vertebral artery

Summary Vein graft reconstruction of the cervical portion of the vertebral artery has been commonly used for the treatment of atherosclerotic arterial disease. In this article, we describe two instances of vein graft replacement of the distal portion of the vertebral artery. In the first case, the vein graft was placed from C₂ transverse foramen to the intradural portion of the vertebral artery to replace an artery abnormally encased and involved by meningioma. The grafting was done in this case to preserve the cerebrovascular reserve in a young patient. In the second, case, a vein graft was placed from the extradural C₁ portion to the intradural artery beyond the posterior inferior cerebellar artery. This was done to replace a segment of the artery involved by a giant aneurysm, which could not be clipped without occluding the parent artery. In this case, the vein graft replacement was necessitated by changes of somatosensory evoked potentials after the aneurysm was clipped, demonstrating the need to preserve the patency of the artery. Vein graft replacement of the proximal intradural vertebral artery is feasible by the combination of standard cerebro-vascular techniques and the exposures afforded by skull base surgery.     

Management outcome for vertebrobasilar artery aneurysms by early surgery.

Treatment of vertebrobasilar artery aneurysms remains fraught with complications, even in the present era of microneurosurgery. In a series of 1150 consecutive patients with cerebral aneurysms from a defined catchment area with 870,000 inhabitants, 93 with vertebrobasilar artery aneurysms were treated by two surgeons during a 14-year period. Sixty-three patients had surgery, 36 during the first week after bleeding. There was no surgical mortality among 33 good grade patients. Nine (14%) of the 63 surgical cases had died at 1 year. Forty-nine (53%) of the total group of 93 patients were functioning independently at 1 year. Overall management mortality was 37%. All 11 patients admitted in Grade V died. In spite of improvements in surgical techniques, we are far from achieving ideal results. Early diagnosis and surgery before rupture are urgently needed. Arteriosclerotic giant aneurysms remain untreatable.     

Assessment of vertebrobasilar artery insufficiency: a clinical audit and literature review.

As cerebrovascular accidents are now increasingly documented in the literature and represent perhaps the most serious side effect of chiropractic upper cervical manipulation, this study was designed to audit the risk assessment process in patients prior to manipulation in a group chiropractic practice. A questionnaire was devised to evaluate the performance of provocational tests and the recording of risk factors. It also examined the procedures carried out in the small numbers of patients who tested positive to vertebrobasilar insufficiency provocation. The audit was carried out in two cycles three months apart. Weaknesses in clinical procedure were identified following the first round audit, and assessment procedures modified in line with recommendations from reviewing the available literature. Improvements were generally evident in the performance of provocation tests, but practitioner recording of historical risk factors at initial consulation, although improved, remained poor. The study is accompanied by a literature review designed to establish the evidence underlying the use of provocational tests, and to consider whether these tests should become mandatory in any forthcoming guidelines for chiropractic practice in this country. After reviewing the evidence available in the biomedical literature, it was apparent that there maybe alterations in blood flow at the upper cervical segment during rotation and extension, but that the vertebral artery is not completely occluded and that the test is therefore not conclusive in identifying patients at risk. The astute practitioner can strengthen their position in this respect by careful assessment of risk factors in the case history, avoiding extremes of rotation and extension and by refraining from repeated rotary manipulations in patients who have experienced post-manipulation dizziness. However, it appears that cerebrovascular accidents can occur even where all these precautions have been taken, that provocation tests are an unreliable indicator and should be omitted from the pre-manipulative recommendations of any future guidelines.     

Angiographic characteristics of the vertebral arteries stenosis in the cerebral blood circulation insufficiency of vertebrobasilar pool

The angiography (AG) is the most important and obligatory part of diagnostic complex. The AG data characterizes mostly full the type and hemodynamical features of the vertebral arteries (VA), which are presented by typical inborn and acquired changes of V1 and V2 segments. Stenotic affection of VA constitutes the indication to surgical treatment.     

Revascularization of the distal portion of the deep femoral artery. Indications and results

Most of the times, the distal part of the deep femoral artery is not affected by atheromatous disease. It constitutes an acceptable alternative, whenever the femoral bifurcation is not usable for bypass. This artery is readily approached directly, at a point removed from Scarpa's fascia. We used this technique on 60 patients. Indications included: multiple reoperations (45 cases, 75%), infection of Scarpa's fascia (2 cases, 3%), calcified or thrombosed femoral bifurcation (13 cases, 22%). Lim salvage for decubital pain, grade-IV or acute ischemic disease involved 49 cases (82%). After a mean 28.5 month follow-up period, arterial permeability was 74% and 53% after one year and 5 years, respectively. These results are compared with literature data. Long-term permeability is related to two factors: proximal bypass implantation site and the state of the popliteal reentry and arterial network of the leg. Utilization of the distal segment of the deep femoral artery via an elective approach is interesting of the deep femoral artery via an elective approach is interesting and sensible, whenever the femoral bifurcation is unusable owing to progressive atheromatous disease, repeated surgery or infection.