Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

SUMMARY: The aim of this study was to compare the clinical value of vertebral artery ultrasound (VAU), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) on vertebral artery stenosis in patients with posterior circulation ischemia. Seventy-three patients with posterior circulation ischemia underwent vertebral artery ultrasound and magnetic resonance angiography as well as digital subtraction angiography, and the diagnosis of vertebral artery stenosis (VAS) and the degree of stenosis (normal, mild stenosis, moderate stenosis, severe stenosis, and occlusion) were recorded and compared between digital subtraction angiogram and vertebral artery ultrasound and magnetic resonance angiography. The vertebral artery stenosis rates on digital subtraction angiography and vertebral artery ultrasound were 87.30 % (55/63) and 49.20 % (31/63), respectively, and the difference was statistically significant. The rates of vertebral artery stenosis on digital subtraction angiography and, magnetic resonance angiography was 90.38 % (47/52) and 88.46 % (46/ 52), respectively, and the differences was not statistically significant. The sensitivity, accuracy, negative predictive value, and positive predictive value of vertebral artery ultrasound in diagnosing vertebral artery stenosis were 51.35 %, 54.76 %, 18.18 %, and 95.00 %, respectively, lower than those of magnetic resonance angiography, which were 91.89 %, 90.48 %, 57.14 %, and 97.14 %, respectively. Of the noninvasive imaging techniques, vertebral artery ultrasound does not accurately characterize vertebral artery stenosis and its degree of stenosis. Magnetic resonance angiography effectively screens for vertebral artery stenosis and its degree of stenosis, and can be used as a reliable tool for vertebral artery stenosis in posterior circulation cerebral infarction, and can be used in conjunction with digital subtraction angiogram in order to improve diagnostic convenience and accuracy.

El objetivo de este estudio fue comparar el valor clínico de la ecografía de la arteria vertebral (VAU), la angiografía por resonancia magnética (ARM) y la angiografía por sustracción digital (DSA) en la estenosis de la arteria vertebral en pacientes con isquemia de la circulación posterior. A 73 pacientes con isquemia de la circulación posterior se les realizó una ecografía de la arteria vertebral y una angiografía por resonancia magnética, así como una angiografía por sustracción digital, y se les diagnosticó estenosis de la arteria vertebral (EVA) y el grado de estenosis (normal, estenosis leve, estenosis moderada, estenosis grave, y oclusión) se registraron y compararon la angiografía por sustracción digital y la ecografía de la arteria vertebral y la angiografía por resonancia magnética. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la ecografía de la arteria vertebral fueron del 87,30 % (55/63) y del 49,20 % (31/63), respectivamente, y la diferencia fue estadísticamente significativa. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la angiografía por resonancia magnética fueron del 90,38 % (47/52) y del 88,46 % (46/52), respectivamente, y las diferencias no fueron estadísticamente significativas. La sensibilidad, precisión, valor predictivo negativo y valor predictivo positivo de la ecografía de la arteria vertebral en el diagnóstico de estenosis de la arteria vertebral fueron 51,35 %, 54,76 %, 18,18 % y 95,00 %, respectivamente, inferiores a los de la angiografía por resonancia magnética, que fueron 91,89 %, 90,48 %, 57,14 % y 97,14 %, respectivamente. De las técnicas de imagen no invasivas, la ecografía de la arteria vertebral no caracteriza con precisión la estenosis de la arteria vertebral y su grado de estenosis. La angiografía por resonancia magnética detecta eficazmente la estenosis de la arteria vertebral y su grado de estenosis, y puede usarse como una herramienta confiable para la estenosis de la arteria vertebral en el infarto cerebral de circulación posterior, y puede ser utilizada junto con la angiografía por sustracción digital para mejorar el diagnóstico y la exactitud.

The effect of dual antiplatelet therapy for improvement of extracranial and intracranial artery stenosis evaluated by digital subtraction angiography

Background: Stroke involving extracranial carotid (ECAS), vertebral (EVAS), and intracranial arteries (IAS) contributed to an annual stroke rate of 0.1-3.3%. Even though endarterectomy and/or angioplasty and stenting had revolutionized its� management, best medical treatment (BMT) is still the mainstay of therapy to prevent secondary stroke/transient ischemic attack. This study aimed to evaluate the effect of BMT to reduce the degree of stenosis by using six-months double antiplatelet therapy (DAPT). Methods: A retrospective cohort study was conducted in a secondary private hospital in Indonesia, in January-December 2022. Adults ?18 years old with ECAS, EVAS, or IAS detected using digital subtraction angiography (DSA), receiving DAPT for at least six months, and those who had second DSA evaluation were included. Any subjects with other brain pathologies or recorded incompliance to DAPT were excluded. Age, gender, stenosis degree, stenosis location, and conversion of stenosis degree were recorded and compared between pre-DAPT and post-DAPT group. Results: Of 30 subjects, there were insignificant changes (46.5�.3% to 50.8�.9%, p=0.09) of ECAS, EVAS, and IAS. There were 14 cases with constant stenosis (51.4�.5%), 8 cases with decreasing stenosis (46.9�.2% to 40.1�.8%, p=0.012), and 12 cases with increasing stenosis (40.4�.9% to 57.1�.0%, p=0.002). No significant association were found among those groups related to traditional vascular risk factors. Conclusions: There was no difference in respect to the degree of stenosis following six months of DAPT in either ECAS, EVAS, or IAS. Routine evaluation as well as recognizing features of high-risk stroke/TIA are important to help decide individual who may be candidates of endovascular procedures earlier.

Successful endovascular reconstruction of symptomatic vertebrobasilar dolichoectasia using multiple Leo stents and nondominant vertebral artery occlusion: a case report

Vertebrobasilar dolichoectasia (VBD) is a rare vascular anomaly of increased diameter, length, and tortuosity of vertebral and/or basilar artery, but debilitating due to its risk of ischemia, hemorrhage, and nerve or brain compression. The management is also controversial due to various possible clinical manifestation and outcome. This study aimed to describe a combined approach of multiple scaffolding Leo stents and nondominant vertebral artery occlusion as a definitive approach to reconstruct vertebrobasilar arteries. A 40-year old male presented with severe headache and reduced consciousness, which was explained with brain CT findings of subarachnoid hemorrhage and hydrocephalus. Further etiologic approach until digital subtraction angiography revealed VBD. An endovascular reconstruction approach was considered one month following the event onset using multiple scaffolding Leo stents from left vertebral to basilar artery with right vertebral artery occlusion. This stent had the best radial strength, lowest bending stiffness, highest kink resistance, highest bending wall coverage, and lowest cell size, which provided strong vascular reconstruction properties. Combined nondominant vertebral artery occlusion was also performed to avoid the disturbance of flow-diverting pathway by the stents. Double antiplatelet was administered from three weeks following the event onset afterwards. The patient抯 condition improved at three-month follow-up. This case report presented that combined multiple Leo stents and nondominant vertebral artery occlusion may be considered as an approach to successful endovascular reconstruction for symptomatic VBD.

Clinical Study on Dingxuan Decoction Combined with Vestibular Function Rehabilitation Training in the Treatment of Meniere's Disease / 广州中医药大学学报

Objective To investigate the efficacy of Dingxuan Decoction combined with vestibular function rehabilitation training in the treatment of Meniere's disease and to observe its effect on clinical symptoms and blood flow of vertebral artery.Methods A total of 100 patients with Meniere's disease of liver-kidney yin deficiency complicated with wind-water upward stirring type were randomly divided into an observation group and a control group,with 50 patients in each group.The control group was given conventional treatment and vestibular function rehabilitation training,and the observation group was treated with Dingxuan Decoction on the basis of treatment for the control group.The two groups were treated for 4 weeks and then were followed up for 6 months.The changes of traditional Chinese medicine(TCM)syndrome score,Dizziness Handicap Inventory(DHI)score,Tinnitus Handicap Inventory(THI)score,hearing visual analogue scale(VAS)score and vertebral artery blood flow in the two groups were observed before and after the treatment.After treatment,the TCM syndrome efficacy,hearing improvement and follow-up results were compared between the two groups.Results(1)After 4 weeks of treatment,the total effective rate for TCM syndrome efficacy of the observation group was 86.00%(43/50),and that of the control group was 62.00%(31/50),and the intergroup comparison showed that the TCM syndrome efficacy in the observation group was significantly superior to that in the control group(P＜0.01).(2)After 4 weeks of treatment,the hearing of patients in both groups was improved,and the total effective rate for the efficacy of hearing improvement in the observation group was 76.00%(38/50),while that in the control group was 46.00%(23/50).The intergroup comparison showed that the efficacy of hearing improvement in the observation group was significantly superior to that in the control group(P＜0.01).(3)After treatment,the TCM syndrome scores,DHI score,THI score and hearing VAS scores in the two groups were all decreased compared with those before treatment(P＜0.05 or P＜0.01),and the decrease in the observation group was significantly superior to that in the control group(P＜0.01).(4)After treatment,the average blood flow velocity of the left vertebral artery(LVA)and the right vertebral artery(RVA)in the two groups were both increased compared with those before treatment(P＜0.05),and the increase in the observation group was significantly superior to that in the control group(P＜0.05 or P＜0.01).(5)The results of 6-month follow-up after treatment showed that the incidence of Meniere's disease and the frequency of attack in the observation group were significantly reduced compared with those in the control group,and the episode duration in the observation group was significantly shorter than that in the control group,the differences being all statistically significant(P＜0.05 or P＜0.01).Conclusion Dingxuan Decoction combined with vestibular function rehabilitation training exert certain effect in treating patients with Meniere's disease of liver-kidney yin deficiency complicated with wind-water upward stirring type,and the therapy is effective on improving patients'clinical symptoms and vertebral artery blood flow,reducing the risk of recurrence and improving the quality of life of the patients.

Clinical efficacy of rapamycin-eluting vertebral artery stents in the treatment of severe ostial vertebral artery stenosis / 介入放射学杂志

Objective To investigate the clinical effect of rapamycin-eluting vertebral artery stent in the treatment of severe ostial vertebral artery stenosis(OV AS),and to analyze the incidence of postoperative in-stent restenosis(ISR).Methods A total of 96 patients with severe OVAS,who received stenting angioplasty at authors'hospital between November 2020 and May 2022,were retrospectively collected.The patients were divided into the observation group(n=48)and the control group(n=48).For the patients of the observation group implantation of rapamycin-eluting vertebral artery stent was carried out,while for the patients of the control group implantation of peripheral balloon dilatation bare metal stent(BMS)was performed.The perioperative basic data,the incidence of complications during follow-up period,and the postoperative incidence of ISR were compared between the two groups.Results Successful stent implantation was achieved in all patients of both groups.During perioperative period no complications such as transient ischemia attack(TIA),dropping-off or fracture of the stent,vertebral artery or stent-related stroke occurred.No statistically significant differences in the length and the diameter of the implanted stents,in the preoperative vertebral artery stenosis ratio,and in the postoperative residual stenosis ratio existed between the two groups(all P＞0.05).In both groups,the postoperative residual stenosis ratio was＜20％.The patients were followed up for a mean period of(12.33±5.82)months(range of 6-18 months),the incidence of postoperative vertebral artery or stent-related stroke in the observation group and the control group was 0％and 4.17％respectively,the difference between the two groups was not statistically significant(P＞0.05).The improvement of clinical symptoms such as dizziness,vertigo,etc.was observed in 47 patients of the observation group and in 45 patients of the control group,and no recurrent posterior circulation TIA or stent-related thrombotic event occurred.The incidence of postoperative restenosis in the observation group was 10.42％,which was significantly lower than 29.17％in the control group(P＜0.05).Conclusion Rapamycin-eluting vertebral artery stent can safely and effectively treat severe OVAS and reduce the incidence of postoperative ISR.(J Intervent Radiol,2024,33:275-279)

Evaluation of high-resolution MRI in patients with posterior circulation ischemic stroke caused by vertebral artery dissection / 实用放射学杂志

Objective To evaluate the imaging features of posterior circulation ischemic stroke caused by vertebral artery dissection(VAD)by high-resolution magnetic resonance imaging(HR-MRI).Methods A total of 56 patients with highly suspected VAD were selected.According to HR-MRI characteristics,these patients were divided into ischemic stroke group(n=23)and control group(n=33).The correlation between imaging features and risk factors in the two groups was analyzed.Results The proportions of intramural hematoma,tumor-like dilatation,and degree of vessel wall enhancement in the ischemic stroke group were significantly higher than those in the control group,and the difference was statistically significant(P<0.05).However,there was no statistical significance in the double-chamber sign and intimal valve sign(P=0.075).Correlation analysis showed that the effective lumen index was significantly negatively correlated with the incidence of posterior circulation ischemic stroke in patients with VAD(r=-0.721,P<0.05),and the area under the curve(AUC)of the effective lumen index reached 0.935.Conclusion The effective features of HR-MRI in the diagnosis of posterior circulation ischemic stroke caused by VAD include intramural hematoma,tumor-like dilatation,degree of vessel wall enhancement,and reduction of effective lumen index,which are helpful for the management and prediction of patients with VAD.

Morphological classification of CT reconstruction of the narrowest part of pediculoisthmic component / 中国组织工程研究

BACKGROUND:It has been suggested that CT multiplanar reconstruction should be performed prior to the placement of axial pedicle screws to determine the anatomy of the C2 pedicle in each patient,to design the appropriate screw locus and diameter,and to evaluate the feasibility of screw placement to reduce the incidence of surgery-related complications. OBJECTIVE:To evaluate the feasibility of axis pedicle screw placement by morphologic classification of pediculoisthmic component with CT multiplanar reconstruction. METHODS:The CT data of 200 patients(400 axial pedicle screws)with cervical spine were retrospectively studied by using Siemens Syngo.Via software.According to the direction of the axis of the pedicle,the CT multiplanar reconstruction positioning line was adjusted to reconstruct the sectional image of the narrowest part of the pediculoisthmic component.According to its morphological characteristics,the narrowest part of the pediculoisthmic component was divided into three types:type 1,"hook"type:Type 1a outer diameter width(a1)>0.4 cm,type 1b outer diameter width(a1)≤0.4 cm;type 2,"like circle/ellipse"type;type 3,"horizontal ellipse"type.The outer diameter width of the narrowest part of pediculoisthmic component(d1),medullary cavity width(d2),outer diameter height(a1),and medullary cavity height(a2)were compared among the three types,and the feasibility of pedicle screw placement of the three types was evaluated. RESULTS AND CONCLUSION:(1)A total of 400 axial pedicles included 269 cases of type 1,130 cases of type 2,and 1 case of type 3.(2)The mean external diameter height between types 1 and 2 was not significantly different(P>0.05).The mean medullary cavity height,mean outer diameter widths,and mean medullary cavity width were significantly different(P<0.001).There were 42 cases(15.6%)of type 1 and 0 cases(0.00%)of type 2 with mean external diameter width≤0.4 cm,and the difference was significant(P<0.001).There was only one case of type 3,whose external diameter height,medullary cavity height,outer diameter width and medullary cavity width were 1.20 cm,0.84 cm,0.64 cm and 0.31 cm,respectively.(3)These results confirm that axial pedicle screws can be safely inserted in patients with types 1a,2 and 3,which requires no further measurement and assessment.Pedicle screw insertion should be performed with caution in type 1b patients.Therefore,in type 1 patients,the width of the narrowest outer diameter of the pediculoisthmic component should be further measured to evaluate the feasibility of axial pedicle screw placement.

Ultrasound for evaluation of vertebral artery course variation / 中国医学影像技术

Objective To observe the value of ultrasonography for evaluating the anatomy and hemodynamic characteristics of vertebral artery course variation(VA-CV).Methods Totally 41 patients with VA-CV(VA-CV group)and 41 patients without VA-CV(control group)were enrolled.Lateral variation of vertebral artery(VA),the origin of V1 segment,the length of proximal subclavian artery(PSCA),the location of VA into the transverse foramen,the diameter of V2 segment,the peak systolic velocity(PSV)and the end-diastolic velocity(EDV)were evaluated with ultrasonography.The value of ultrasonography for evaluating VA-CV and relative hemodynamic changes were analyzed.Results Totally 49 variant VA were detected in VA-CV group,including 19 on the left and 30 on the right side,VA-CV on the right side was more often than on the left side.Seventeen(16 on the left and 1 on the right side)VA had abnormal origins,and abnormal VA origins on the left side were more than that on the right side(P＜0.001).Meanwhile,VA origins of right VA-CV were mostly lower than that of the left side VA-CV(P＜0.001).The length of right PSCA in VA-CA group was shorter than that in control group(P＜0.05).More than half variant VA entered vertebral space from the transverse foramen of C5-6(33/49,67.35％),and the higher the entrance of transverse foramen,the shorter the PSCA(P＜0.05).In VA-CV group,the diameter of V2 segment in left VA-CV patients was smaller than that in control group,while EDV in the former was lower than in the latter(both P＜0.05).Conclusion Ultrasonography could be used to objectively evaluate VA-CV and relative hemodynamic changes.

Analysis of the clinical characteristics of V4 segment steal blood in the vertebral artery / 中华内科杂志

Objective:To explore the clinical characteristics of unilateral vertebral artery V4 segment occlusive lesions (severe stenosis or occlusion), where the contralateral vertebral artery can be compensated through blood flow and reverse supply to the posterior inferior cerebellarartery (PICA).Methods:This study is a retrospective case series of 66 patients with V4 segment occlusive lesions of unilateral vertebral artery diagnosed and treated from June 2020 to October 2022. Patient data were retrospectively collected, and their hemodynamic characteristics and imaging data were analyzed.Results:Of the 66 cases, 11 patients (16.7%) with V4 segment occlusive disease showed the blood flow of the vertebral artery on the opposite side of the lesion on the digital subtraction angiography (DSA), which can be reverse stolen to the posterior inferior cerebellar artery of the diseased side through the confluence point of the vertebrobasilar artery through the distal end of the ipsilateral vertebral artery V4. Owing to the lack of literature on this pathway and based on the characteristics of previous definitions of subclavian artery steal and carotid artery steal, we referred to this pathway as the vertebral artery V4 segment steal. In 6 patients (9.1%), transcranial Doppler ultrasound (TCD) and transcranial color Doppler ultrasound (TCCD) showed that the blood flow signal was not detected at the proximal end of the V4 segment of the affected side, rather the blood flow direction was reversed at the distal end of the V4 segment, resulting in compensatory acceleration of the blood flow velocity of the V4 segment of the contralateral vertebral artery.Conclusion:“V4 segment steal of vertebral artery” is a very rare route of vertebral artery steal. When V4 segment of the vertebral artery is occluded, clinicians should pay attention to observe the blood supply of PICA and whether there is such a steal route, to better evaluate the blood flow compensation and prognosis of patients.

Safety and strategy of intravascular intervention in ruptured intracranial vertebral artery dissecting aneurysm / 中华神经医学杂志

Objective:To investigate the safety and efficacy of intravascular intervention in ruptured intracranial vertebral artery dissecting aneurysm (IVADA).Methods:A retrospective analysis was performed; 25 patients with ruptured IVADA (25 aneurysms) admitted to Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China from January 2020 to June 2023, were chosen. Aneurysm and parent artery occlusion or stent-assisted spring coil embolization were performed according to location of the aneurysms, degrees of aneurysm immediate embolization were evaluated by Raymond grading, and perioperative adverse events were recorded. The patients were followed up for 6-48 months, and aneurysm recurrence was determined according to DSA results; prognoses were assessed by modified Rankin Scale (mRS), with scores of 0-2 as good prognosis and scores of 3-6 as poor prognosis.Results:All 25 patients had unilateral ruptured IVADA, 10 (40%) received aneurysm and parent artery occlusion (occlusion of dissection segment) and 15 (60%) received stent-assisted embolization. Immediately after surgery, 19 patients (76%) had grading I embolization, 4 (16%) grading II embolization, and 2 (8%) grading III embolization. No aneurysm rupture or stent related thrombosis was observed during procedure; 3 patients (12%) died after procedure, with postoperative rebleeding in 1, postoperative cerebellar infarction with respiratory failure in 1, and severe pneumonia in 1. In the 22 survivals, 18 had good prognosis and 4 had poor prognosis. In the 5 relapsed patients (all accepted stent-assisted embolization), 4 underwent re-intervention, and one with visualization at aneurysm neck was relatively stable on re-examination and accepted regular follow up.Conclusion:Aneurysm and parent artery occlusion can be used for non-dominant vertebral artery aneurysms not involving posterior inferior cerebellar artery, whose recurrence rate is lower than that of stent-assisted coil embolization.

Feasibility study of low tube voltage and low contrast medium combined with IMR technology in 3DCTA of vertebral artery V3 segment / 重庆医学

Objective To investigate the feasibility of low-voltage,automatic tube current adjustment(ATCM)and low contrast agent concentration,dose and injection rate combined with full-model iterative re-construction(IMR)in vertebral artery V3-segment three-dimensional CT angiography(3DCTA).Methods A total of 60 patients with suspected upper cervical spine,craniocervical junction lesions undergoing cervical vertebral artery V3 segment 3DCTA in this hospital from November 2019 to May 2020 were selected and divided into the group A and B by adopting the random number table method,30 cases in each group.The group A adopted the ATCM technology of 80 kV,average tube current of 50 mAs,25 mL of contrast agent io-hexol(iodine content 300 mg/mL)combined IMR technology with an injection rate of 3 mL/s,while the group B adopted 120 kV,150 mAs fixed tube current,50 mL injection rate of 5 mL/s contrast agent iopamidol(iodine content 370 mg/mL)combined filter back projection(FBP)reconstruction technology.CT value,noise,signal-to-noise ratio(SNR),contrast noise ratio(CNR)and image sensitivity(FOM)were measured and compared between the two groups and the quality of the resulting images was evaluated.The CT volumet-ric dose index(CTDIvol)and dose-length product(DLP)were recorded,and the effective dose(ED)was cal-culated.Results There was no statistically significant difference in the vertebral arterial CT value between the two groups(P＞0.05),but the noise of the group A was lower than that of the group B(P＜0.05),SNR,CNR and FOM of the group A were greater than those of the group B(P＜0.05).The image quality of the two groups met the requirements of clinical diagnosis[(4.78±0.41)points vs.(4.85±0.35)points],and there was no statistically significant difference in the subjective evaluation of image quality(P＞0.05).The CTDIvol,DLP and ED levels in the group A were lower than those in the group B(P＜0.05).The iodine in-takes of contrast medium in the group A and group B were 7.5 g and 18.5 g,respectively,and the iodine flow rates of contrast agent were 0.9 and 1.85 mg/s,respectively,and compared with group B,the iodine intake and iodine flow rate of the group A were decreased by 59.5％and 51.4％,respectively.Conclusion Low tube voltage ATCM and low contrast concentration,dose and injection rate combined with IMR technology can not only ensure the 3DCTA image quality of vertebral artery V3 segment,but also reduce the radiation dose re-ceived by the patients,and reduce the iodine intake and iodine flow rate of contrast agent.

Vertebral Artery Stenosis Caused by Cervical Osteophyte: A Rare and Reversible Cause of Vertebrobasilar Insufficiency. Case Report / Estenose da artéria vertebral causada por Osteófito Cervical: Uma causa rara e reversível de insuficiência vertebrobasilar. Relato de caso

Bow Hunter syndrome manifests when the vertebral artery is compressed following head rotation. Symptomatic compression with vertebral artery stenosis due to cervical osteophytes is a rare cause and occurs due to a progressive degenerative process. In most cases, compression originates anteromedially from the uncinate process and is asymptomatic due to the competence of the contralateral vertebral artery. In the described patient, compression presented superomedially due to osteophytes in the superior articular facet of the C5 vertebra, and the contralateral vertebral artery was obstructed. Careful evaluation with imaging, mainly preoperative 3D angiotomography, is necessary to determine the most beneficial approach for decompression. The treatment of choice for symptomatic compression induced by cervical spondylosis is decompression surgery.

A síndrome de Bow Hunter se manifesta quando a artéria vertebral é comprimida após a rotação da cabeça. A compressão sintomática com estenose da artéria vertebral devido a osteófitos cervicais é uma causa rara e ocorre devido a um processo degenerativo progressivo. Geralmente, a compressão se origina anteromedialmente do processo uncinado e é assintomática devido à competência da artéria vertebral contralateral. No paciente descrito, a compressão se apresentou superomedialmente devido a osteófitos na faceta articular superior da vértebra C5, e a artéria vertebral contralateral estava obstruída. Uma avaliação cuidadosa com imagens, principalmente angiotomografia 3D pré-operatória, é necessária para determinar a abordagem mais benéfica para a descompressão. O tratamento de escolha para compressão sintomática induzida por espondilose cervical é a cirurgia de descompressão.

Dynamic computed tomography angiography for noninvasive diagnosis of bow Hunter's syndrome: a case report

ABSTRACT The focus of this case report is to technically describe a noninvasive diagnostic evaluation of bow Hunter's syndrome using a dynamic computed tomography angiography protocol and discuss its advantages. In addition, we aimed to exemplify the quality of the study by presenting images of a 3D-printed model generated to help plan the surgical treatment for the patient. The dynamic computed tomography angiography protocol consisted of a first image acquisition with the patient in the anatomic position of the head and neck. This was followed by a second acquisition with the head and neck rotated to the side that triggered the symptoms, with technical parameters similar to the first acquisition. The acquired images were used to print a 3D model to better depict the findings for the surgical team. The dynamic computed tomography angiography protocol developed in this study helped visualize the vertebrobasilar arterial anatomy, detect vertebral artery stenosis produced by head and neck rotation, depict the structure responsible for artery stenosis (e.g., bony structure or membranes), and study possible complications of the disease (e.g., posterior cerebral circulation infarction). Additionally, the 3D-printed model better illustrated the findings of stenosis, aiding in surgical planning. In conclusion, dynamic computed tomography angiography for the evaluation of bow Hunter's syndrome is a feasible noninvasive technique that can be used as an alternative to traditional diagnostic methods.

Temporalidad y factores de riesgo asociados al desarrollo de un infarto cerebral en pacientes con disección de arterias cervicales / Temporality and factors associated with the development of a cerebral infarction in patients with cervical artery dissection

INTRODUCCIÓN: Las disecciones de arterias cervicales (DAC) son la primera causa de accidente cerebrovascular isquémico (ACVi) en personas jóvenes. Los factores asociados (FA) de ACVi y la relación temporal con la DAC no están bien caracterizados. Tampoco disponemos de una clasificación clínico-radio-lógica que permita conocer el riesgo de ACVi. OBJETIVO: Describir frecuencia y FA y temporalidad de los ACVi en pacientes con DAC. MÉTODOS: Estudio prospectivo de pacientes mayores de 18 años hospitalizados por una DAC carotidea y/o vertebral entre agosto de 2009 y junio de 2017. Las DAC se diagnosticaron clínico-radiológicamente y los ACVi con imagen con infarto. Se utilizo la Clasificación de Borgess para caracterizar radiológicamente las DAC. Se utilizaron análisis de regresión logística uni y multivariable para evaluar las características clínico-radiológicas y los FA. RESULTADOS: 163 pacientes con 182 DAC (60% vertebrales y 40% carotídeas). 73 pacientes (44,8%) tuvieron un ACVi 28 de 68 pacientes (41,2%) tuvieron simultáneamente síntomas de disección y de isquemia. 60 de 68 pacientes (88%) presentan síntomas de isquemia durante la primera semana. FR significativamente asociados a ACVi: Borgess tipo IB (p = 0,001; OR: 4,1; IC: 1,8-9,3), sexo masculino (p < 0,001; OR: 0,2; IC: 0,06-0,8) y anticonceptivos orales (p = 0,02; OR: 0,2; IC: 0,06-0,8). CONCLUSIÓN: Ocurre aproximadamente en la mitad de los pacientes, en su mayoría dentro de la primera semana, no es la forma habitual de presentación inicial y no se relaciona con el tipo de arteria disecada. El principal FA para desarrollar un ACVi fue la oclusión arterial (Borgess tipo IB).

INTRODUCTION: Cervical artery dissections (CAD) are the leading cause of ischemic stroke (CVA) in young people. The risk factors for stroke and the temporal relationship with CAD are not well characterized. Nor do we have a clinical-radiological classification that allows knowing the risk of stroke. OBJECTIVE: To describe the associated factors and temporality of ACVi in patients with CAD. METHODS: We performed a prospective study that included patients over 18 years of age, hospitalized for carotid and/or vertebral CAD between August 2009 and June 2017. CAD cases were diagnosed clinically and radiologically; ACVi was diagnosed when the imaging study demonstrated infarction. The Borgess Classification was used to characterize the CAD radiologically. For correlation studies, we used univariate and multivariate logistic regression analyses. RESULTS: We analyzed 163 patients with 182 CAD (60% vertebral and 40% carotid). 28 of 68 patients (41.2%) simultaneously had symptoms of dissection and ischemia. 60 of 68 patients (88%) presented symptoms of ischemia during the first week. CAD: Borgess type IB (p = 0.001; OR: 4.1; CI: 1.8-9.3), male (p < 0.001; OR: 0.2; CI: 0.06- 0.8) were significantly associated with ischemic strokes and oral contraceptives (p = 0.02; OR: 0.2; CI: 0.06-0.8). CONCLUSION: Stroke associated with CAD has a relatively low frequency. It is not related to the type of dissected artery. It mainly occurs not simultaneously with CAD and within the first week. The main associated factor for developing a stroke is arterial occlusion (Borgess type IB).1,8-9,3), male sex (p < 0.001; OR: 0.2; CI: 0.06-0.8) and oral contraceptives (p = 0.02; OR: 0.2; CI: 0.06-0.8).

Infarction in middle cerebellar peduncle caused by ipsilateral vertebral artery hypoplasia

AICA (anterior inferior cerebellar artery) is a ramification of the basilar artery. It originates in the lower or middle third of the basilar artery at the junction of the medulla oblongata and pons. A young 33-year-old male presented with an unsteady gait, left-sided facial hypoesthesia, and hearing impairment on the left side. On neurological evaluation, he was found to have left-sided sensorineural deafness and signs of incoordination. A brain magnetic resonance image (MRI) was suggestive of an acute infarct in the left middle cerebellar peduncle and a hypoplastic left vertebral artery recognized on MRA. We presented a case report wherein a patient presented with clinical features of a middle cerebellar peduncle infraction caused by hypoplasia of the left vertebral artery.

The prevalence, clinical characteristics, and brain MRI changes in intracranial artery hypoplasia: a retrospective single-center cross-sectional study

reduced cerebral blood flow, increased atherosclerosis, and aneurysm formation. This study aimed to describe the profile of vertebral artery hypoplasia (VAH), anterior CAH (ACAH), and posterior CAH (PCAH) in symptomatic subjects. Methods: This was a retrospective cross-sectional study using medical record in a secondary private hospital in Jakarta, Indonesia, in January-December 2022. The inclusion criteria were age ?18 years with neurological symptoms, underwent brain MRI, and being diagnosed with CAH using DSA. The exclusion criteria were findings of other vascular pathologies including dissection and >50% intracranial vessel stenosis. Demographics of age, sex, body mass index (BMI), hypertension, diabetes, cardiac disorder, and previous stroke were analyzed among VAH, PCAH, and ACAH groups. Results: Of 769 subjects with clinical symptoms undergoing DSA, there were 66 (8.6%) cases of intracranial artery hypoplasia, including VAH (4.6%), PCAH (1.2%), and ACAH (2.9%). Subjects were predominantly old (53.2±10.1 years), male (53.0%), with BMI of 24.9±3.9 kg/m2 and hypertension (69.7%). Previous stroke (69.7%) was more prevalent than in previous study (28.1%). Stroke and brain ischemic lesion were detected in 89.4% and 84.8% cases. No differences were found in all parameters among all groups, but posterior circulation symptoms tended to be found in VAH (28.1%) than general stroke (20.3%). Conclusions: The high percentage of recurrent stroke and corresponding clinical symptoms associated with CAH supported that CAH may be a risk factor for clinical symptoms, including stroke, regardless of the involved artery.

Bilateral Variation of the Vertebral Artery: Report of a Case and its Clinical Implication / Variación Bilateral de la Arteria Vertebral; Reporte de un Caso y su Implicancia Clínica

SUMMARY: There are many reports on anatomical variations of the vertebral arteries, which may be related to origin, trajectory, caliber, and side. Bilateral variations are less frequent, however, and less common are bilateral variants that differ from each other. The aim of this work was to report the presence of a bilateral variation of the vertebral artery and its functional and clinical implications. Dissection of a female cadaver, fixed in 10 % buffered formaldehyde, which had not undergone any previous surgeries in the study area and had anatomical variations in both vertebral arteries. In each one, follow-up was done from its origin to its end, determining its trajectory, diameters, branching, and anatomical relations. A left vertebral artery was found, starting in the aortic arch and making a sinuous trajectory of 4 curvatures to enter the transverse foramen of C4. The right vertebral artery began as the first branch of the subclavian artery. Its initial trajectory was rectilinear, followed by a right concave curve, a 360° loop that included a second ascending curve, and ended straight before entering the transverse foramen of C6. The coexistence of bilateral variations in the vertebral arteries is possible. This atypical situation can potentially generate vascular and neurological pathologies, but with different symptoms and causes. Knowing these variations and deliberately searching for them will enable the specialist to make a suitable differential diagnosis.

Existen múltiples reportes sobre variaciones anatómicas de las arterias vertebrales, las que se pueden relacionar con origen, trayecto, calibre y lateralidad. Sin embargo, las variaciones bilaterales son menos frecuentes, y menos común es que las variantes bilaterales sean diferentes entre ellas. El objetivo de este trabajo fue reportar la presencia de una variación bilateral de la arteria vertebral y su implicancia funcional y clínica. Disección en un cadáver de sexo femenino, fijado en formaldehido tamponado al 10 %, el cual no presentaba intervenciones quirúrgicas previas en la región de estudio y que tenía variaciones anatómicas en ambas arterias vertebrales. En cada una se realizó seguimiento desde su origen hasta su terminación, pudiendo determinar su trayecto, diámetros, ramificaciones y relaciones anatómicas. Se encontró una arteria vertebral izquierda originada en el arco aórtico, que realizaba un trayecto sinuoso de 4 curvaturas e ingresaba al foramen transverso de C4. La arteria vertebral derecha se originaba como primera rama de la arteria subclavia. Su trayecto inicial era rectilíneo seguido por una curva de concavidad derecha, un loop (giro) de 360° que incluía una segunda curva ascendente y terminaba en dirección recta antes de ingresar al foramen transverso de C6. La coexistencia de variaciones bilaterales en las arterias vertebrales es posible. Esta situación atípica, potencialmente puede generar en la persona patologías neurológicas de origen vascular, pero con sintomatología y causas diferentes. Conocer estas variaciones y realizar una búsqueda intencionada de ellas permitirá el especialista realizar un adecuado diagnóstico diferencial.

Morphometric Study of Atlas Vertebra In Relation to Sulcus Arteriae Vertebralis

Background: Atlas(C1) is an atypical cervical vertebra shaped like a ring. Important structures like the vertebral artery, suboccipital plexus of veins and first cervical nerve pass through it. Knowledge of the variability of C1 is important for neurosurgeons, orthopaedicians, otorhynologists and other physicians who in everyday practice are in contact with disorders of the spine and their consequences. So, this study was undertaken to assess the various dimensions of the C1 in relation to the vertebral artery groove. Methods and materials: Fifty dried human atlas vertebrae were studied. Various measurements were done and statistically analysed. Results: Antero-posterior diameter (APD) of Foramen transversarium(FT) was measured as 7.73 ± 1.04mm on the right and 7.62 ± 0.90mm on left side. Transverse Diameter(TD) of FT was observed as 6.12 ± 0.97mm on the right side and 6.02 ± 0.97mm on the left side. Outer Distance of Vertebral Artery Groove(VAG) was measured as 26.22 ± 2.32mm and 25.84 ± 1.85mm on the right and left sides, respectively. Inner Distance of VAG was observed as 13.10 ± 1.66mm on right and 13.17 ± 1.57mm on the left side. APD of Superior Articular Facet(SAF) was 21.52 ± 2.36mm on right and 21.51 ± 2.07mm on left side.TD of SAF was 11.21 ± 1.47mm on right and 11.32 ± 1.53mm on left side. APD of Inferior Articular Facet(IAF) was observed as 17.54 ± 1.50mm on right and 17.70±1.60mm on left side. TD of IAF was observed as 14.99 ± 1.65mm on the right side and 14.94 ± 1.51mm on left side. Distance between lateral-most edge of both Foramen Transversaria was measured as 56.37 ± 4.11mm and distance between medial-most edge of both Foramen Transversaria was 44.78 ± 3.67mm. MaximumTD of Atlas was measured as 72.09± 5.59mm. Conclusion: The study will generate information that would be useful for geometric modelling of vertebrae and give necessary morphometric data on human atlas vertebra in Indian population.

Study of Incidence of Ponticulus Posterior In Dry Human Atlas Vertebra and Its Clinical Significance

Background: Atlas is the first cervical vertebra. The vertebral artery lies in the groove on posterior arch of the atlas. The vertebral artery groove may sometimes get converted into a foramen. This is commonly known as ponticulus posterior (ponticulus posticus) or arcuate foramen of the atlas. These foramina may be complete or incomplete. This can lead to compression of the vertebral artery and produce symptoms like headache, syncope, altered consciousness etc. It can also complicate manipulations of the cervical spine by reducing the blood flow during extreme rotations of head and neck. It is also associated with vertebrobasilar artery stroke So, neurosurgeons or orthopaedic surgeons who operate in this area should have a detailed knowledge of variations of groove for the vertebral artery. Materials and Methods: The present study was conducted on 50 dried and fully ossified adult human atlas of unknown age and sex collected from the department of Anatomy, Government Medical college, Nagpur. Each atlas vertebra was carefully observed for the presence or absence of complete or incomplete ponticuli on superior surface of posterior arch of atlas. Results: Out of the 50 vertebra studied 7(14%) showed the presence of Ponticuli. Ponticuli were incomplete in all 7 atlas vertebras. Complete ring was not observed in any of the atlas vertebra .Out of the 7 ponticuli 6(12%) were found to be unilateral and in only 1 (2%) case it was found to be bilateral. Out of the 6 ponticuli 4(8%) were noticed on the Left side and 2(4%) were present on the right side. Conclusion: Presence of incomplete ponticulus posterior might cause cervical pain and even cerebrovascular disorders due to pressure on third part of vertebral artery present in the vertebral artery groove. This anatomical knowledge is important for neurosurgeons, orthopaedic surgeons, radiologists and clinicians while dealing with this region.

Experimental study of improved sclerotherapy injection in rat model of vertebral arteriocervical spondylopathy / 中国骨伤

OBJECTIVE@#To improve the rat model of cervical spondylosis of vertebral artery type (CSA) induced by injecting sclerosing agent. To evaluate the efficacy of injecting sclerosing agent to induce CSA.@*METHODS@#Forty Health SPF SD rats(20 males and 20 females), were randomly divided into two groups:the model group (20) and the blank group (20). All the animals were followed up for 4 weeks for the observation of general situation, transcranial Doppler(TCD) detection of blood flow velocity, pulsatility index and resistive index of the vertebral artery, measurement of mental distress by open-field test.@*RESULTS@#One to two days after establish the animal model, rats in the model group appeared apathetic with decreased autonomic activities, trembling, squinting, increased eye excrement, etc., and no rats died during the experiment. The mean blood flow velocity of the model group was lower than that of the blank group (P<0.05), and the pulsatilit index and resistive index of the model group were higher than that of the blank group (P<0.05). The mental distress of the model group was significantly higher than that of the blank group.@*CONCLUSION@#The modified injection of sclerosing agent is a practical method to establish the rat model of CSA, with high success rate, high stability, low mortality and simple operation.