Application of Vaso CT in the recanalization of vertebrobasilar junction occlusion / 中国脑血管病杂志

Objective To investigate the risk assessment,guiding role,and clinical value of Vaso CT image features for recanalization of vertebrobasilar junction occlusion. Methods From January 2016 to May 2017,14 patients with vertebrobasilar junction occlusion admitted to the Department of Neurology, Chinese PLA General Hospital were analyzed retrospectively. Preoperative cerebral angiography confirmed vertebrobasilar junction occlusion. Vaso CT was used to measure the length of the occluded vessels and vascular direction at both ends. According to these results, the operative risks were evaluated and the recanalization of vertebrobasilar junction occlusion were guided. Results The length of vertebrobasilar junction occlusion was 2. 56-19. 09 mm (mean 4. 5 ± 2. 1 mm) in 14 patients,and 13 of them were treated with the recanalization of vertebrobasilar artery occlusion,the blood vessels of 12 cases were successfully recanalized and stent placement was performed after the recanalization,among them,8 Solitaire stents and 4 Wingspan stents were implanted;One patient did not perform recanalization because of longer length of occlusion (19. 09 mm). All patients operated did not have any perioperative complications, and the neurological symptoms were significantly improved after procedure. Conclusion Vaso CT can accurately determine the surgical risk of the recanalization of vertebrobasilar junction occlusion,and can guide the surgical pathways,reduce the incidence of perioperative complications,and improve the success rate of the operation.

Application of Vaso CT in the recanalization of vertebrobasilar junction occlusion / 中国脑血管病杂志

Objective To investigate the risk assessment,guiding role,and clinical value of Vaso CT image features for recanalization of vertebrobasilar junction occlusion. Methods From January 2016 to May 2017,14 patients with vertebrobasilar junction occlusion admitted to the Department of Neurology, Chinese PLA General Hospital were analyzed retrospectively. Preoperative cerebral angiography confirmed vertebrobasilar junction occlusion. Vaso CT was used to measure the length of the occluded vessels and vascular direction at both ends. According to these results, the operative risks were evaluated and the recanalization of vertebrobasilar junction occlusion were guided. Results The length of vertebrobasilar junction occlusion was 2. 56-19. 09 mm (mean 4. 5 ± 2. 1 mm) in 14 patients,and 13 of them were treated with the recanalization of vertebrobasilar artery occlusion,the blood vessels of 12 cases were successfully recanalized and stent placement was performed after the recanalization,among them,8 Solitaire stents and 4 Wingspan stents were implanted;One patient did not perform recanalization because of longer length of occlusion (19. 09 mm). All patients operated did not have any perioperative complications, and the neurological symptoms were significantly improved after procedure. Conclusion Vaso CT can accurately determine the surgical risk of the recanalization of vertebrobasilar junction occlusion,and can guide the surgical pathways,reduce the incidence of perioperative complications,and improve the success rate of the operation.

Rupture of the Giant Vertrbrobasilar Aneurysm After Hunterian Vertebral Artery Occlusion / 대한뇌혈관외과학회지

A 32-year-old woman with a giant vertebrobasilar junction aneurysm underwent a Hunterian coil occlusion. Two months later she was readmitted with aggravation of her previous symptoms. Shortly after the admission, fatal bleeding occurred. She underwent emergency surgery and the aneurysm was trapped by clipping at the vertebrobasilar junction; however, she died. For treating unclippable giant vertebrobasilar aneurysms, proximal vertebral occlusion is an alternative. By occluding the proximal parent artery, we expect reduced inflow of blood into the aneurysm and thereby induce intra-aneurysmal thrombus formation. Based on the experience with this patient in which the hemodynamics resulted in continued pressure on the inner wall of the giant aneurysm, we postulate that Pascal's law might play a role in the rupture of a giant aneurysm after Hunterian occlusion.

Giant Vertebrobasilar Junction Aneurysm Treated with Proximal Occlusion of Parent Artery Followed by Coil Embolization of Partially Thrombosed Aneurysm: A Case Report / 신경중재치료의학

In the case of giant vertebrobasilar junction aneurysm with an outflow directly draining into the basilar artery, trapping of ipsilateral vertebral artery is technically challenging. Endosaccular coil embolization may be an option, but it may aggravate symptoms due to mass effect or aneurysmal regrowth after coil compaction. Occlusion of the ipsilateral vertebral artery proximal to the aneurysm may be another option. However, complete thrombosis should be eventually achieved to prevent symptom progression from the retrograde flow or mass effect by the partial thrombosis within the aneurysm. The authors describe a case of giant vertebrobasilar aneurysm initially treated with proximal occlusion. As the aneurysm getting partial thrombosis, the bulbar compression symptom was slowly aggravated. We performed endosaccular coiling of small remaining sac 2 months later, which resulted in complete resolution of compression symptom.

Far Lateral Approaches for Intracranial Aneurysms / 대한뇌혈관학회지

Surgical approaches to the posterior circulation aneurysms are difficult and still remained as a matter of debate. Many skull base approaches has been developed to overcome the inadequate exposure of these aneurysm by conventional surgical approaches. Far lateral approaches are an extension of suboccipital approach to expose neurovascular structures around the lower clivus. Aneurysms locating at the vertebral arteries, vertebrobasilar junction and lower basilar artery could be exposed by these approach. However, it is not still evident which kind of far lateral approach is most appropriate for the aneurysms of various locations at these vascular territory. Among the 3 kinds of far lateral approaches, such as far lateral, far lateral transcondylar and extreme lateral transcondylar approach, far lateral approach is not recently used frequently. Far lateral transcondylar approach is good far the aneurysm at the origin of posterior inferior cerebellar artery and the extreme lateral transcondylar approach is useful to expose aneurysms around vertebrobasilar junction. For an appropriate selection of surgical approaches, useful surgical guidelines are mandatory. The recent use of "intermeatal line" and "K lines" and others are of many help for the lower basilar and vertebral artery aneurysms. Surgical approach itself needs knowledge and experience for an adequate performance. Once exposed appropriately manipulation of aneurysms at these locations are not very complicated. Microsurgical anatomy of each surgical step is essential for the sucessful management of aneurysms locating at the lower clivus.

Anatomy of Vertebral and Posterior Inferior Cerebellar Artery / 대한뇌혈관학회지

Vertebral artery(VA) and posterior inferior cerebellar artery(PICA) have complex and variable anatomic configuration of origin and running course in its exctracranial and intracranial pathway. VA has four main segments: the first portion from their origin to the entry into the foramen transversarium of C6, V1; the second portion from the C6 foramen to the C1 foramen, V2; the third portion from the exit from the C1 foramen to their entry through the atlanto-occipital membrane, V3; and the fourth portion from the entry through the dura to the vertebrobasilar junction, V4 after usual origin from proximal subclavian artery. Anatomic variations including aplasia, hypoplasia, duplication, and fenestration have been reported and careful consideration and examination must be needed because these variations tend to have another vascular anomalies such as arteriorvenous malformation or aneurysm. Tortuosity of VA is not a unusual finding especially in the aged people and the branches of VA are composed of meningeal, spinal, muscular, and radicular artery. PICA is most prominent artery from VA and its trunk is divided into five segments: anterior medullary, lateral medullary, tonsilomedullary, telovellotonsillar, and cortical. The running pathway of this vessel is pretty various in each person. The branches of this vessel are composed of perforating, terminal (cortical), choroidal, and meningeal artery. The extradural origin of PICA is infrequent; however, awareness of the presence of such an anatomic variation may be a helpful adjunct to avoid injury to this vessel. Around the vertebrobasilar junction (VBJ), the anatomy of the main arteries was variable. In contrast, the perforators penetrated the adjoining brain stem at specific locations regardless of caliber of the main artery. The four major point of entry to brain stem are the lateral medullary area just caudal to the posterior olivary sulcus (Group I), the posterior olivary sulcus(Group II), the small lateral fossa at the superior olivary groove(Group III), and the foramen caecum(Group IV). Despite a small VA or its major branches, the perforators penetrating the brain stem are very important and may effect the outcomes of operation or neurointerventional procedure of VBJ unless careful manipulation and consideration was performed.

Anatomy of Vertebral and Posterior Inferior Cerebellar Artery / 대한뇌혈관학회지

Vertebral artery(VA) and posterior inferior cerebellar artery(PICA) have complex and variable anatomic configuration of origin and running course in its exctracranial and intracranial pathway. VA has four main segments: the first portion from their origin to the entry into the foramen transversarium of C6, V1; the second portion from the C6 foramen to the C1 foramen, V2; the third portion from the exit from the C1 foramen to their entry through the atlanto-occipital membrane, V3; and the fourth portion from the entry through the dura to the vertebrobasilar junction, V4 after usual origin from proximal subclavian artery. Anatomic variations including aplasia, hypoplasia, duplication, and fenestration have been reported and careful consideration and examination must be needed because these variations tend to have another vascular anomalies such as arteriorvenous malformation or aneurysm. Tortuosity of VA is not a unusual finding especially in the aged people and the branches of VA are composed of meningeal, spinal, muscular, and radicular artery. PICA is most prominent artery from VA and its trunk is divided into five segments: anterior medullary, lateral medullary, tonsilomedullary, telovellotonsillar, and cortical. The running pathway of this vessel is pretty various in each person. The branches of this vessel are composed of perforating, terminal (cortical), choroidal, and meningeal artery. The extradural origin of PICA is infrequent; however, awareness of the presence of such an anatomic variation may be a helpful adjunct to avoid injury to this vessel. Around the vertebrobasilar junction (VBJ), the anatomy of the main arteries was variable. In contrast, the perforators penetrated the adjoining brain stem at specific locations regardless of caliber of the main artery. The four major point of entry to brain stem are the lateral medullary area just caudal to the posterior olivary sulcus (Group I), the posterior olivary sulcus(Group II), the small lateral fossa at the superior olivary groove(Group III), and the foramen caecum(Group IV). Despite a small VA or its major branches, the perforators penetrating the brain stem are very important and may effect the outcomes of operation or neurointerventional procedure of VBJ unless careful manipulation and consideration was performed.