Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.

A case of Von Meyenburg Complex associated with calculous cholecystitis, cerebral aneurysm and renal cortical cyst / 대한내과학회지

Von Meyenburg complexes (VMC) have many synonyms such as bile duct hamartomas and biliary hamartoma. These rare benign disorders are considered as congenital diseases caused by malformed differentiation of ductal plate. The diagnosis of VMC by common radiologic modality such as ultrasound and computed tomography was nearly impossible until the emergence of cholangiopancreatography by magnetic resonance imaging (MRCP) and the pathologic examination was the only way to confirm the diagnosis of VMC. But MRCP is now considered as most accurate noninvasive method for diagnosis of VMC. We report a histologically proven case of VMC associated with calculous cholecystitis, cerebral aneurysm and renal cortical cyst. To our knowledge, no comparable case has been reported and this would be the only second reported case of VMC, which was diagnosed by MRCP.

Regional Cerebral Blood Flow on Cerebral Reperfusion after Occlusion of Bilateral Common Carotid Arteries : An Experimental Cat Model

The microvasculature of the brain is also quite susceptible to ischemic insult, and substantial portions of the brain are not reperfused after restoration of the blood supply following overtime of critical ischemic periods. The purpose of this series of experiments was to determine the effects of ischemia on subsequential regional cerebral blood flow measurements and cortical electric activities following reperfusion after ischemia and also to define the proper time of vascular occlusion without irreversible neural damage. Cerebral ischemia was induced in cat by bilateral common carotid occlusions for periods of 10, 30, to 60 minutes, and the blood flow(rCBF) was measured by hydrogen clearance technique following ischemia, restoration of blood supply and electroencephalogram recovery could be predicted according to the rCBF. Forty adult cats weighing 2.7 to 4.0kg were used in this study. The animals were divided into 4 groups of 10 cats each : normal control, 10 min-clamped, 30 min-clamped, and 60 min-clamped groups. The results obtained were as follows : 1) The mean rCBF was 24.6+/-7.0ml/100g/min in control group. 2) Bilateral carotid occlusions resulted in a reduction of the rCBF (12.4+/-4.1ml/100g/min) to 50% of control flow on both hemispheres. 3) Sequential changes of the rCBF after reperfusion. (1) There was restored the rCBF(21.3+/-5.1ml/100g/min) to control flow in the 10 minutes-clamped group. (2) There was a 85% recovery of control flow in the 30 minutes-clamped group. (3) There was a only 25% recovery of control flow in the 60 minutes-clamped group. 4) A close correlation was found between cortical electrical activity and rCBF suggesting a threshold relationship. (1) The changes of cortical electric activity began to notice at rCBF less than 17.4+/-4.7ml/100g/min. (2) The changes of cortical electric activity noted at rCBF more than 10.2+/-2.3ml/100g/min. 5) There was no evidence of ischemic involvement at the cortex, white matter and basal ganglia in the 10 minutes clamped group, but demonstrated a dense wedge shaped infarct at the cortex and uncus herniation in the 60 minutes clamped group. The rCBF and cortical electric activity restorted to normal values in reperfusion within 10 minutes after occlusion of both common carotid arteries.

Somatosensory Evoked Potential Responses in Focal Brain Lesions

Cerebral somatosensory evoked potentials(SEPs) produced by stimulation of peripheral nerves provide a useful diagnostic index of conduction in somatosensory pathways to the cortex. Thus the integrity of both the dorsal column-medial lemniscus pathway and primary sensorimotor area has been considered an essential requirement to record a normal SEP. There are suggestions that SEPs contain several components arising from different neuronal sources, the early short latency potentials corresponding to the lemniscus-mediated responses and the late waves to the diffuse spino-thalamic projections. The present work analyses the influence on SEPs of focal brain lesions, using the computerized tomography in detecting and localizing brain lesions. Somatosensory evoked potentials were recorded in 20 patients with focal brain lesions recognized by computerized tomography. 1) Patients with primary sensorimotor area(PSMA) damages(group I) had a very abnormal of the early component(No, Po, Nl, Pl) in 100% on the lesion side. 2) Patients presented supratentorial lesions, sparing PSMA(group II), 87.5% showing abnormal SEPs in early components and characterized by increment of amplitude in late components. 3) Brainstem damage(group III) produced a distortion of the early components especially N11, N20msec in latency. 4) In incomplete spinal cord injuries, the SEPs is indeed signal of functional recovery, of posterior column, and incorrespondance with clinical improvement.

Regression of nodules on cranial computerized tomography (CCT) scans in focal epileptic patients

Epilepsy can be defined as a paroxysmal, neuronal discharge within the brain originating from either corticalor sugcortical regions. The incidence of epilepsy is increasing possibly due to the survival of persons who shouldhave died of brain injuries or other cerebral abnormalities acquired in earlylife. the use of abtibiotics andimprovement in the medical care have saved many children who might have died of meningitis, brain abscess,encephalitis, severe head injuries, etc. CCT scan is new radiologic procedure for defining cranial andintracranial structures and also an useful procedure for evaluation and follow-up(FU) of patient with focalseizure disorder. Recently we experienced nodules which were isodense or hypodense on initial noncontrasted CT(NECT) and scans became hyperdense of the enhancement in 4 cases of focal epileptic seizures. Nearly completedisappearance or regression of the epileptic foci occurred on the FU CT scans in 2 cases. Operation was performedin 2 cases. The tissue specimen obtianed from the CT nodule revealed cerebral edema in one case and localizedgliosis and congestion in the other. All the patients showed marked clinical improvement when the CT noduleimporved. Review of literature failed to disclose any previous report on such observation.

Basal Ganglia Calcification and Hypoparathyroidism: Case Report

Microscopic calcification within the basal ganglia was reported by Virchow and Bamberger in 1855. The description of symmetrical cerebral calcification, particularly of the basal ganglia and often of the dentate nuclei, associated with hypoparathyrodism as related by Eaton, Camp and Love(1939) was a significant development in the field of calcification. Calcification of the basal ganglia has been visualized by skull radiography and computed tomography(CT) scan, and in two-third of cases, it has been associated with metabolic and endocrine abnormalities. Computed tomography is more sensitive to detect the intracranial calcification than plain skull radiography. The purpose of our report was evaluate the significance of basal ganglia calcification as visualized by CT, discusses on pathogensis of calcification, clinical significance and management under the hypocalemia.

Effect of the Thiopental in Acute Focal Cerebral Infarction after Experimental Occlusion of the Middle Cerebral Artery

An experimental ischemic model in cats is described in which we have attempted to produce acute cerebral ischemia by occlusion of the middle cerebral artery(MCA) through the orbit. The main objectives of this experiment were:to observe the effect of thiopental in the tophographic distribution of infarct;the size of the infarct;histological changes of ischemic nerve cells following occlusion of a major cerebral artery;to investigate the best timing of the administration and dosage of thiopental after the occlusion. 80 adult cats weighing 2.7 to 4.0kg, were used in this study. The components of the pathophysiological responses, systemic changes, cerebral infarct size and histopathological ischemic neuronal changes were studid in these groups of animals. We observed the protective effect of the thiopental on acute focal cerebral ischemia in 40 cats by effecting permanent occlusion of MCA. The EEG was monitored continuously using bifrontal electrodes from the time of administration of thiopental(10mg/kg). The animals were divided into 4 groups of 20 cats each. The 4 different groups were used to investigate the effects of thiopental on focal ischemia according to different time interval. The time intervals were 6 hours, 24 hours, 48 hours, and 72 hours after occlusion of MCA. Each animal group were divided into two groups, which one was control(n=10) the other, thiopental treated group(n=10). The results obtained were as follows: 1) Blood gases, artrial pressure, body temperature, and intracranial pressure differed among groups only as follows: (a) Normal blood pressure was maintained but pulse rate was slightly fast in each control group. (b) Blood pressure and pulse rate in the thiopental treated groups were significantly lower than in the control groups. In the thiopental treated groups, the value of PaO2 was significantly higher than control groups, however, PaCO2 was not significantly higher in the thiopental treated groups as compared to the control group. 2) In the control groups, severe contralateral hemiplegia(grade III) developed in the early stage of MCA occlusion, however the neurological deficit progressively improved to the state of abnormal climbing(neurological grade II) 48 hours to 72 hours after the occlusion. In the thiopental treated groups, minimum to mild neurological deficit significantly developed in the early stage of MCA occlusion and in one case walking ability was regained. 3) The size and distribution of the infarct significantly decreased to 60% in the thiopental treated groups(p<0.01). The value of the size of the size of the infarct in the thiopental treated groups 72 hours after occlusion was minimized to 0.3+/-0.6%(p<0.01). In 80 percent of the control group cases severe extensive ischemic neuronal damage(score 3 or 4), was observed, 70 percent in the thiopental treated groups showed mild ischemic nerve cell changes(score 1 or 2) when the histological examination was given. Although the severity of the ischemic neuronal damage was gradually improved from 6 hours to 72 hours after occlusion of the MCA in the control, the thiopental treated group was not significantly affected to the time factor. 4) Significantly reduction of experimentally induced acute focal cerebral ischemia was associated in the cat model with the administration of thiopental at 5 minute, 30 minute, and one hour postocclusion. Also we have defined the best barbiturate, best does, and best timing of administration to protect the acute focal ischemia.

A Case of Congenital Dermal Sinus with Dermoid Cyst of Posterior Fossa

Congenital dermal sinuses are dermal tubes which extended inward from the surface for varying distances and frequently connect the central nervous system or its covering with the surface of the body. The inner end of the sinus may be expanded to form a dermoid or epidermoid cyst. They are the results of incomplete separation of the epithelial ectoderm from the neuroectoderm at the fourth week of fetal development. As cystic expansion of a congenital sinus which is located within the cranium or spinal canal may act as any other mass lesion to interrupt neurologic function by local compression or it may obstruct the normal circulation of spinal fluid. In addition, because of its persistent communication with the skin surface, it serves as a constant potential port of entry for infection into the central nervous system. Since the first report in 1926 by Moise of staphyloccus meningitis secondary to a congenital sacral sinus, numerous reports have appeared of infection secondary to congenital sinuses along the craniospinal axis, particulary in the suboccipital region. Authors report a case of congenital dermal sinus associated with dermoid cyst of posterior fossa which was successfully removed and discuss the pathegenesis of it in embryology, and surgical management of it's complications.

The Mega Cisterna Magna: Report of 4 Cases

The size of the cisterna magna is still detatable. Robertson13) stated that the cisterna magna varies greatly in capacity and described the large cisterna magna as a separate entity. He also found that in most cases the cisterna magna extended approximately 2.5cm above the foramen magnum and was usually 5mm deep with a variable width. Liliequist8) proposed a mean heigh of 28mm for the normal cisterna magna with a wide variation of 15 to 60mm, and a depth of 6mm at the foramen magnum with a variation of 2 to 10mm:however, he did not quote measurements for the width. Gonsette, et al.5) reported 28 cases of enlarged cisterna magna diagnosed by ventriculography and coined the phrase "mega grande citerne" or mega cisterna magna. All of these cases, however, had symptoms of posterior fossa disease. Our study of the syndrome of the mega cisterna magna without specific syndrome is presented nystagmus, transient syncope in the first & third cases were operated under suboccipital craniectomy and was confimed the large cisterna magna. This paper presents the clinical diagnosis with vertebral angiogrraphy, pneumoencephalography and computed tomography.

The Effect of THIOPENTAL and MANNITOL of Acute Intracranial Hypertension in Severe Head Injury and the Other Comatous Patients

Laboratory and clinical evidence indicates a potentially important role for barbiturates in the management of brain injury and intracranial hypertension. The present report describes our experience with the thiopental and mannitol therapy in 30 consecutive patients who were over 20mmHg of intracranial pressure(ICP) in severe head injuries and the other comatous conditions. The anothers have analyzed the effects of thiopental on outcome in comatous 30 patients by continuous monitoring of ICP. High dose barbiturate therapy was induced with an intravenous bolus of thiopental, 40mg/kg and the infusion of barbiturates intermittently continued until control of the ICP(below 20mmHg) was obtained. In those patients responding to thiopental, the daily mannitol requirement was reduced from 3.5 to 0.5mg/kg/day. Our overall results are presented; 1) In patients with intracranial mass lesions only very high ICP(>40mmHg) on barbiturate management was significantly associated with a poor neurological deficit and outcome from injury, while the patients with any increased in ICP above 20 to 29mmHg was associated with a moderate neurological disability and better outcome with thiopental and mannitol treatment. 2) In patients with surgical mass lesion ICP between 20 to 29mmHg was significantly associated good neurological picture and outcome, but the patients in ICP above 40mmHg, had a 75% motality. 3) Decreases in ICP over 20mmHg were seen in 75%of the patient who had managed with thiopental and mannitol. 4) Thiopental responders have returned to a good recovered and minimal deficit, but thiopental nonresponsiveness was associated with a completely unfavorable outcome:5 deaths, 1 vegetative survior.

Aneurysm of the Great Vein of Galen: Case Report

Aneurysms of the great vein of Galen are rare and the authors report a case of primary type aneurysm of the great vein of Galen. Clinicaly aneurysm of great vein of Galen give rise to different symptoms and signs at different age. New born infants have intractable heart failure, infancy have hydrocephalus, and adolescents have headache and syncope. The diagnosis rests upon angiography, especially four-vessel angiography is mandatary to delineate all of the feeding arteries. The posterior cerebral arteries supply most of the blood to the aneurysm. The only effective treatment is ligation of the feeding vessels at the point of entry into the vein of Galen.

Total Excision of an Arterio-Venous Malformation of the Corpus Callosum: Case Report

The arteriovenous malformations(AVMs) of the corpus callosum are distinct anatomical and surgical entities. The AVMs of the corpus callosum are supplied by the pericallosal arteries if the malformations are located in the anterior and middle portion of the callosum and the AVMs of the splenium are usually fed by the pericallosal and posterior cerebral arteries. Radical excision of the callosal AVMs became successful with microsurgical techniques since a few years ago. The authors report a case of the callosal AVM, who had subarachnoid hemorrhage twice prior to this admission, and the studies with angiography and computed tomography revealed an AVM involing the middle portions of the corpus callosum. Radical excision of the AVM was accomplished by microsurgical techniques without neurologic sequela.

Three Cases of Syringomyelia with Operative Treatment

Authors experienced the myelotomy for the syringomyelia in 3 cases. Moreover a recent case who underwent the craniovertebral decompression with myelotomy was associated with Arnold-Chiari malformation. Post-operative courses were uneventful in two but a case with the thoracic myelotomy became paraparetic after 5 years of follow up due to the spinal arachnoiditis. It seems that the careful studies, including the ventriculography and/or C-T scan are necessary to find the hind-brain malformation and to give the appropriate management.

A Case of Carotico-Cavernous Fistula Treated by Intraluminal Occlusion

A case of carotico-cavernous fistula was managed by intravascular occlusion using a Fogarty catheter and ligation of the carotid artery. The fistula was obliterated by the procedure and neurologic deficits improved progressively without further recurrence. The radiological feature, symptomatology and surgical management were discussed.

A Case of Intracranial Arachnoid Cyst

The intracranial arachnoid cyst is distinctly uncommon and they have unusual clinical course. The plain skull series were usually shown bulging of the overlying skull due to progressive collection of cerebrospinal fluid in cystic cavity. Pre-operative diagnosis is unlikely to be made. The predilection sites of this lesion are usually convexity of hemisphere, cisterna chiasmaticus, especiaily forebrain along the axis of main cerebral artery. The authors report a case of intracranial arachnoid cyst arisen along the Sylvian fissure combined chronic subdural hematoma follwoing sustained mild head injury. The pathologic diagnosis was arachnoid cyst, since the removed cyst wall was normal arachnoid tissue.

Two Cases of Pituitary Apoplexy

Attention has been called to the sudden expansion of a pituitary tumor by hemorrhage within it, causing sudden loss of vision. Management of the pituitary apoplexy should be regarded as a neurological emergency. The outstanding clinical features of acute pituitary apoplexy were sudden headache, depressed consciousness, opthalmoplegia, meningismus and signs of compression of the optic nerve or chiasm. The authors report two cases of pituitary apoplexy, one was chromophobe adenoma and pathological diagnosis was not obtained in the other. The first case was 45-year-old man admitted to the Department of Neurosurgery, Catholic Medical Center on June 20, 1977, with headache, double vision and impared left side visual acuity. On April 26, 1977, he experienced sudden severe headache and diplopia then became drowsy. The headache and impairment of consciousness improved subsequently. He was admitted to a university hospital following the onset. The work up at the hospital revealed an enlarged sella with hazy dorsum sellae on plain skull films. The carotid angiogram revealed an elevation of the A1 segments bilaterally and cisternal pneumogram revealed an evidence of suprasellar extension of the pituitary tumor. He was advised to have immediate surgery. The patient, however, refused the surgery and noticed the impaired visual acuity and diplopia were persisting. The studies in this hospital revealed marked impairment of left side vision and oculomotor nerve palsy of the left eye. The carotid angiogram and cisternal pneumogram revealed the no evidence of sellar mass or suprasellar extension of the tumor. The second case was 59-year-old woman admitted to the neurosurgical ward on September 30, 1977, after a sudden onset of severe bifrontal headache, vomiting, bilateral ocular pain and drowsy mental state. She was drowsy with panopthalmoplegia of the right side, and spinal fluid was xanthochromic. Skull X-ray, carotid angiogram and air study revealed an evidence of pituitary tumor with minimal suprasellar extension. Removal of pituitary tumor through the trans-sphenoidal approach was performed, and the tumor was proved to be chromophobe adenoma. Panopthalmoplegia was progressively improved postoperatively.

Hydrocephalus in Ruptured Intracranial Aneurysm

Authors analysed 74 cases of hydrocephalus which developed as a sequela of the ruptured intracranial aneurysm for the incidence correlated to the site of aneurysm and the detection time of hydrocephalus. We also studied the outcome of hydrocephalus following the aneurysm surgery. Correlations between the frequency of hydrocephalus and the intracerebral hematoma, the vasospasm, and the number of bleeding were attempted. Followings are the results : 1) Of the 207 cases of ruptured aneurysms, the incidence of hydrocephalus was 35.8%. Most common site of aneurysm associated with hydrocephalus was vertebrobasilar, internal carotid, middle cerebral, and anterior communicating artery in turn. 2) Of the 74 cases hydrocephalus after the ruptured aneurysm, the incidence of hydrocephalus which was persistent in spite of aneurysm surgery was 11.1% of cases. 3) It has shown that 89% of hydrocephalic cases were recoverd after the aneurysm surgery. 4) Hydrocephalus was detected after aneurysm surgery in 8% of cases who had no evidence of ventricular dilatation preoperatively. 5) The hydrocephalus was frequently detected from 2 to 4 weeks after hemorrhage from the intracranial aneurysm although it was not uncommon to find hydrocephalus in a week. 6) The hydrocephalus developed after aneurysm surgery was frequently found 3 to 4 weeks post-operatively. 7) Repeated hemorrhage and incidence of hydrocephalus, a sequela of the ruptured intracranial aneurysm was not closely related.

Diagnosis of Brain Lesion with Vertebral Angiography

The authors analysed radiologic findings of the posterior fossa lesions as well as incisural and supratentorial lesions in 40 patients who were diagnosed by transfemoral serial vertebral angiography at Catholic Medical Center since October 1972 to April 1976. We also attempted to evaluate the diagnostic value in the diagnosis of the lesions according to the site of involvement. The tumors of the fourth ventricle or vermis demonstrated abnormal findings corresponding to the area of involvement, however the lesion could not be defined accurately with the study. Cerebellar hemispheric or tentorial tumors were diagnosed with considerable accuracy by vertebral angiography. Infratentorial vascular lesions were clearly demonstrated with serial vertebral angiography but the accuracy of diagnosis was argumented with subtraction technique. The evidence of compression of the brain stem was demonstrated with considerable accuracy by serial vertebral angiography. Furthermore exact site and direction of the compression could be outlined with the study. For the posterior temporal or occipital tumors which were not able to diagnose definitely with carotid angiography, considerable diagnostic accuracy was carried by the vertebral angiography. Definite diagnosis of the posterior third ventricle tumors or thalamic lesions was able to obtain with serial vertebral angiography.

Chondroma of the Sphenoid Sinus: Case Report

Although intracranial cartilaginous tumor are distinctly uncommon, they have several distinct features. They are slow growing tumors with predirection for the base of skull and plain skull roentgenegram often demonstrates destruction and calcification at the site of the tumors. The authors report a case of cartilaginous tumor arisen from the sphenoid sinus with characteristic features. Biopsy yielded the pathologic diagnosis of chondroma.

Upper Brain Stem Lesions Diagnosed by Serial Vertebral Angiography

We have experienced 17 cases of the upper brain stem compression lesions diagnosed by serial vertebral angiography and other ancillary studies from October, 1972 to August, 1975. All the cases were proven by serial vertebral angioraphy using the Seldinger catheter technique through the femoral artery and other studies such as carotid angiography, conray ventriculograpy, brain scan and pneumoencephalography. Angiographical analysis were attempted. The results were as following: 1. The location of lesion is:supratentorial lesions; 8 cases, infratentorial lesions; 5 cases, tentorial lesions; 3 cases, bilateral hippocampal herniation due to otitic hydrocephalus; 1 case. 2. We have tried to classify the upper brain stem compression lesions according to the direction of compression, i.e., (1) forward, (2) medial, (3) backward and (4) downward and analyzed their angiographic findings in detail. 3. Lesions compressed the upper brain stem forward were one case of bilateral occipital meningioma, one case of fourth ventricle tumor, two cases of medulloblastoma and one case of cerebellar hemispheric tumor. Their main angiographic findings were as follows;(1) Separation of quadrigeminal segment of superior cerebellar artery and posterior cerebral artery, (2) Compression of basilar artery against clivus and depression or elevation of bifurcation of basilar artery, (3) Stretching of thalamoperforating artery, (4) Elevation and forward basilar artery, (3) Stretching of thalamoperforating artery, (4) Elevation and forward displacement of posterior mesencephalic vein and posterior displacement of precentral cerebellar vein, (5) Elevation of vein of Rosenthal. 4. Lesions compressed the upper brain stem medially were two cases of parietal ependymoma, one case of temporal meningioma, one case of bilateral hippocampal herniation and three cases of tentorial tumors. Their main angiography findings were as follows; (1) Medial displacement of posterior cerebral artery, superior cerebelar artery, bifurcation of basilar artery, distal portion of vein of Rosenthal, lateral mesencephalic vein and internal cerebral vein in Towne's view, (2) Elevation or depression of posterior mesencephalic vein, (3) Depression of bifurcation of basilar artery, (4) Stretching of thalamoperforating artery, (5) Depression of crural and ambient segment of superior cerebellar artery. 5. Lesions compressed the upper brain stem backward were one case of pituitary tumor and one case of cerebellopontine angle tumor. Their main angiographic findings were as follows; (2) Posterior displacement of distal portion of basilar artery, (2) Posterior displacement of anterior pontomesencephalic vein, (3) Elevation of posterior cerebral artery and superior cerebellar artery, (4) Elevation of vein of Rosenthal and posterior mesencephalic vein, (5) Stretching and elevation of posterior communicating artery. 6. Lesions compressed the upper brain stem downward were one case of thalamic tumor, one case of thalamic hemorrhage, and one case of pinealoma. Their main angiographic findings were as follows; (1) Stretching of posterior cerebral artery and superior cerebellar artery, (2) Displacement and stretching of internal cerebral vein, vein of Rosenthal and posterior mesencephalic vein, (3) Depression of bifurcation of basilar artery, (4) Stretching of thalamoperforating artery, (5) Depression of posterior cerebral artery and superior cerebellar artery, (6) Depression of internal cerebral vein, vein of Rosenthal, posterior mesencephalic vein and anterior pontomesencephalic vein. 7. We have concluded that in order to diagnosis the upper brain stem compression lesions serial vertebral angiography is the most important procedure and at the same time the analysis of the arteriographic and venographic findings in detail is important.