Endovascular management of dissecting posterior cerebral artery aneurysm associated with persistent hypoglossal artery: A case report / Tratamento endovascular do aneurisma dissecante da artéria cerebral posterior associado à artéria hipoglossa persistente: relato de caso

Abstract Persistent embryological connections between the anterior and posterior circulations are rare entities. Persistent hypoglossal artery is the second most common persistent carotid-basilar anastomosis. As it is often associated with hypoplasia of vertebral arteries, it poses a challenge during endovascular interventions. We present a case of a 32-year-old woman who presented with occipital headache of four weeks' duration. Magnetic Resonance Angiography showed hypoplastic vertebral arteries with a persistent hypoglossal artery arising from the cervical segment of the left internal carotid artery and supplying the entire posterior circulation, associated with a dissecting aneurysm of the right posterior cerebral artery. Endovascular parent vessel occlusion was performed for the dissecting posterior cerebral artery aneurysm by navigating the guide catheter, microwire, and microcatheter through the persistent hypoglossal artery because the vertebral arteries were hypoplastic. Post-intervention, the patient did not develop any neurological deficit and was discharged in a stable condition.

Resumo Conexões embriológicas persistentes entre as circulações anterior e posterior são entidades raras. A artéria hipoglossa persistente é a segunda anastomose carotídeo-basilar persistente mais comum. Como está frequentemente associada à hipoplasia das artérias vertebrais, apresenta um desafio durante as intervenções endovasculares. Apresentamos o caso de uma mulher de 32 anos que apresentou cefaleia occipital com duração de quatro semanas. A angiografia por ressonância magnética mostrou artérias vertebrais hipoplásicas com artéria hipoglossa persistente surgindo do segmento cervical da artéria carótida interna esquerda e suprindo toda a circulação posterior com um aneurisma dissecante da artéria cerebral posterior direita. A oclusão endovascular do vaso parental foi realizada para o aneurisma da dissecção da artéria cerebral posterior pela passagem de cateter guia, microfio e microcateter pela artéria hipoglossa persistente, pois as artérias vertebrais eram hipoplásicas. Após a intervenção, a paciente não apresentou déficit neurológico e recebeu alta em uma condição estável.

Presentation of cerebral and cervical arterial dissections in Botucatu, Brazil: case series / Apresentação de dissecções arteriais cerebrais e cervicais em Botucatu, Brasil: uma série de casos

Abstract Spontaneous dissection of the cervical and cerebral arteries is an important cause of stroke and disability in young patients. In this report, the authors present a case series of patients with spontaneous carotid, vertebral, or cerebral artery dissection who underwent digital angiography. A review of the published literature on this subject is also presented.

Resumo A dissecção espontânea das artérias cervicais e cerebrais é uma causa importante de acidente vascular cerebral e incapacidade em pacientes jovens. Neste relato, é apresentada uma série de casos de pacientes com dissecção espontânea da artéria carótida, vertebral ou cerebral submetidos à angiografia digital. Além disso, é fornecida uma revisão da literatura sobre esse assunto.

Arteritis de células gigantes en el sistema vertebrobasilar, isquemias cerebelo-occipitales y parálisis III par: caso clínico / Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve: report of one case

Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.

Aberrant Origin of Vertebral Artery and its Clinical Implications

Abstract Aberrant origin of vertebral artery is rare. The anatomical features and clinical significance of this lesion remain to be clarified. A comprehensive collection of the pertinent literature resulted in a cohort of 1286 cases involving 955 patients and 331 cadavers. There were more left than right and more unilateral than bilateral aberrant vertebral arteries. Patients with aberrant origin of vertebral artery were often asymptomatic and in only 5.5% of the patients their symptoms were probably related to the aberrant origin of vertebral artery. The acquired cardiovascular lesions were present in 9.5% of the patients, 20.9% of which were vertebral artery-associated lesions. Eight (0.8%) patients had a vertebral artery dissection. Logistic regression analysis showed significant regressions between bovine trunk and left vertebral artery (P=0.000), between the dual origins of vertebral artery and cerebral infarct/thrombus (P=0.041), between associated alternative congenital vascular variants and cervical/aortic dissection/atherosclerosis (P=0.008). Multiple logistic regression demonstrated that side of the aberrant origin of vertebral artery (left vertebral artery) (P=0.014), arch branch pattern (direct arch origin) (P=0.019), presence of the common trunk (P=0.019), associated acquired vascular disorder (P=0.034) and the patients who warranted management (P=0.000) were significant risk predictors for neurological sequelea. The patients with neurological symptoms and those for neck and chest operations/ interventions should be carefully screened for the possibility of an aberrant origin of vertebral artery. The results from the cadaver metrology study are very helpful in the design of the aortic stent. The arch branch pattern has to be taken into consideration before any maneuver in the local region so as to avoid unexpected events in relation to aberrant vertebral artery.

Giant Pseudoaneurysm as a delayed Surgical Complication in a Patient Operated on a Giant Neuroma of the Vagus Nerve: Case Report and Management Considerations / Pseudoaneurisma gigante como complicação cirúrgica em paciente operado com neuroma gigante do nervo vago: relato de caso e considerações

The vertebral artery has four segments. The horizontal portion of the V3 segment is the most exposed portion of the vertebral artery to potential iatrogenic injuries during surgical approaches to the posterior fossa.We present an unusual case of a patient who was operated on a giant neuroma of the left vagus nerve, with incidental vertebral artery iatrogenic injury, the development of a delayed giant pseudoaneurysm, and the treatment for this complication. We conclude that endovascular treatment may be a good option for the management of this serious surgical complication.

A artéria vertebral tem quarto segmentos. A porção horizontal do segmento V3 é a mais exposta a potenciais lesões iatrogênicas durante procedimento cirúrgico de acesso à fossa posterior. Apresentamos caso incomum de paciente submetido à cirurgia para neuroma gigante no nervo vago esquerdo, com acidental lesão da artéria vertebral iatrogênica, desenvolvimento de posterior pseudoaneurisma gigante e tratamento para esta complicação. Concluímos que o tratamento endovascular pode ser uma boa opção para o cuidado desta grave complicação cirúrgica.

Hipoplasia de la arteria vertebral su importancia clínica en el síndrome de wallenberg / Hypoplasia Of The Vertebral Artery Its Importance In Wallenberg Syndrome Clinic

Introducción: Este trabajo describe la existenciade una variante anatómica: La hipoplasia de las arteriasvertebrales, definida como un estrechamiento de su diámetro luminal (< 2-3 mm) que conlleva una disminuciónde la velocidad del flujo sanguíneo encefálico. Material yMétodo: En nuestra experiencia se disecaron 20 encéfalos formalizados al 10% de la Cátedra de Anatomía de la Fac. de Cs. Médicas de la Universidad Nacional de Córdoba con técnica de disección clásica. Resultados: La arteria vertebral izquierda es dominante con respecto a la vertebral derecha y que emergen del segmento V4. Conclusión: La importancia del conocimiento anatómico de la arteria vertebral y sus variables facilita el diagnóstico precoz de la presencia de hipoplasia arterial, la cual se asocia a ciertos trastornosneurológicos, como son la migraña con aura, la isquemia cerebelar, (Sindrome de Wallemberg), disección de laarteria vertebral o cambios ateroescleróticos.

Introduction: This paper describes the existencean anatomical variant: hypoplasia of the arteriesvertebral defined as a narrowing of luminal diameter (<2-3 mm) which leads to a decreaseof cerebral blood flow velocity. Material andMethod. In our experience 20 brains formalized 10% of the Department of Anatomy, Faculty of Cs were dissected. Medical, National University of Cordoba with classical dissection technique. Results: The left vertebral artery is dominant with respect to the right vertebral V4 and emerging segment. Conclusion: The importance of anatomical knowledge of the vertebral artery and variables facilitates the early diagnosis of the presence of arterial hypoplasia, which is associated with certain disordersneurological disorders, such as migraine with aura, cerebellar ischemia (Wallenberg Syndrome), dissectionvertebral artery or atherosclerotic changes.

Hypoplasia of Left Vertebral Artery with Intimal Fibromuscular Dysplasia in a Korean Woman

We found a case of hypoplasia of vertebral artery with fibromuscular dysplasia in an 82-yr-old Korean female cadaver during a routine dissection course. In the present case, intracranial hypoplasia in left vertebral artery and bilateral origin of posterior inferior cerebellar artery at the vertebrobasilar junction were recognized. Histopathologically, left vertebral artery showed intimal type of fibromuscular dysplasia both in its extracranial and intracranial courses. These results indicate that the association of fibromuscular dysplasia and hypoplasia does exist in the vertebral artery, although the etiologies are not verified yet.

Arteritis de Takayasu: informe de un caso con compromiso supraaórtico y tratamiento quirúrgico / Takayasu's arteritis: report of a case with supraaortic compromise and surgical treatment

La arteritis de Takayasu es una vasculitis inflamatoria crónica de grandes vasos. Fue descrita por primera vez por el oftalmólogo japonés Nikito Takayasu, en el año 1908. Presentamos un caso de arteritis de Takayasu, diagnosticada clínicamente de acuerdo a los criterios del American College of Rheumatology de 1990. Se trata de una paciente de 23 años que ingresa al Hospital Regional de Talca por un accidente vascular encefálico hemisférico y sintomatología de robo subclavio. Se realiza un angio TAC que muestra compromiso severo (oclusión total) del tercio medio y distal del tronco braquiocefálico, carótida común derecha e inicio de la subclavia derecha. Además, este examen demuestra un flujo retrógrado en la arteria vertebral derecha, compatible con el síndrome de robo subclavio. Se decide corregir la oclusión subclavia mediante angioplastía, sin éxito tanto en el abordaje anterogrado como retrógrado. Finalmente se opta por un bypass protésico (politetrafluoroetileno expandido) desde la carótida común izquierda a la subclavia derecha a través de un túnel subcutáneo en la cara anterior del cuello.

Takayasu's arteritis is a chronic inflammatory vasculitis of large vessels. It was first identified by Japanese ophthalmologist Nikito Takayasu, in 1908. A case of Takayasu's arteritis is presented, clinically diagnosed according to the criteria of the American College of Rheumatology of 1990. This is a 23 year oíd patient, entering Talca's Regional Hospital for a stroke, also presenting symptoms of subclavian steal. An angio CT was made, showing severe commitment (total occlusion) in the middle and distal third of the brachiocephalic trunk, right common carotid and the beginning of right subclavian artery. In addition, this test shows retrograde flow on the right vertebral artery, compatible with the subclavian steal syndrome. It was decided to correct the subclavian occiusion through angioplasty, without success, in both the anterograde and retrograde approach; finally opting for a prosthetic bypass (expanded polytetrafluoroethylene) from left common carotid to right subclavian artery through a tunnel of the subcutaneous front of the neck.

Spontaneous Dissecting Aneurysm of the Intracranial Vertebral Artery: Management Strategies

PURPOSE: Pathogenesis and treatment of spontaneous dissecting aneurysm of the intracranial vertebral artery (VA) remain controversial. This study was designed to provide management strategies and to improve management outcome in patients with these aneurysms. MATERIALA AND METHODS: Among a total of 1,990 patients treated for intracranial aneurysms from February 1992 to June 2005, 28 patients (1.4%) were treated either by surgery (8 patients) or neurointervention (20 patients) for spontaneous dissecting aneurysms of the intracranial VA. Twenty-two patients had ruptured aneurysms. We analyzed indications of surgery or neurointervention for each case, and assessed the management outcome at a 6-month follow-up. RESULTS: For selection of therapeutic options, patients were initially evaluated as possible candidates for neurointervention using the following criteria: 1) poor clinical grade; 2) advanced age; 3) medical illness; 4) unruptured aneurysm; 5) equal or larger opposite VA; 6) anticipated surgical difficulty due to a deep location of the VA-posterior inferior cerebellar artery (PICA) junction. Surgery was considered for patients with: 1) high-risk aneurysms (large or irregular shaped); 2) smaller opposite VA; 3) failed neurointervention; or 4) dissection involving the PICA. Management outcomes were favorable in 25 patients (89.3%). Causes of unfavorable outcome in the remaining 3 patients were the initial insult in 2 patients, and medical complications in one patient. CONCLUSION: Ruptured aneurysms must be treated to prevent rebleeding. For unruptured aneurysms, follow-up angiography would be necessary to detect growth of the aneurysm. Treatment modality should be selected according to the clinical characteristics of each patient and close collaboration between neurosurgeons and neurointerventionists is essential.

Anatomical organization of aortic arch variations in the India: embryological basis and review

Objectives: To determine the percentage and type of aortic arch variations in Indian subjects and their clinical surgical importance and embryological basis. Patients and methods: In our investigation, branching patterns of the aortic arch were studied in 62 formalinfixed cadavers of booth sexes of Indian origin, aged 45-79. The dissections were carried out in formalin preserved after exposing the thoracic and cervical region during routine dissection of undergraduate students of Indiam origin in Kasturba Medical College, Mangalore. Results: The usual three-branched aortic arch was found in 56 cadavers (91,4 percent); variations were found in six cadavers (9,6 percent); 4,8 percent presented common origin of the carotid arteries; 1,6 percent had biinnominate sequence, and the same specimen had left coronary artery arising from arch of aorta directly; 1,6 percent presented right subclavian artery arising directy from the aorta; 1,6 percent had left vertebral artery a branch of aortic arch...

Hemifacial spasm resulting from vertebral artery dolichoectasia

A 32-year-old man presented with left hemifacial spasm. Neurophysiological findings revealed an absent ipsilateral R1 on blink reflex. An MRI showed a dolichoectatic left vertebral artery impinging on the root exit zone of the left facial nerve. Botulinum toxin infections relieved the manifestations of hemifacial spasm. This case demonstrates that MRI/MRA is an essential part of the work-up for hemifacial spasm, and shows that in accordance with the literature, vertebral dolichoectasia is an uncommon cause of hemifacial spasm

Extracranial vertebral arteriovenous fistula presenting as an osteolytic lesion of the axis: Case report

Arteriovenous fistulas of the extracranial vertebral artery are rare. The authors report a case of a spontaneous arteriovenous fistula of the extracranial vertebral artery presenting as an osteolytic lesion at the body of the axis. The patient presented with headache and posterior neck pain. The fistula was obliterated by an endovascular trapping.

Estudio ultrasonográfico (Duplex Doppler) del diámetro y velocidad de las arterias vertebrales y su relación con la edad y la patología vertebral y arterial del cuello / Ultrasonic duplex scanning of the diameter and velocity of the vertebral arteries flow: its relation with age, vertebral pathology and arterial pathology of the neck

Un grupo de pacientes con síntomas de insuficiencia cerebrovascular fueron estudiados con el método doppler (duplex) de las arterias carótidas y vertebrales. Este artículo describe las relaciones entre el diámetro arterial vertebral y la velocidad del flujo en función a la edad y a la presencia significativa de estenosis carotidea (interna y externa) concomitante homolateral

Análisis comparativo entre la angiografía digital y la imagen por resonancia magnética de cortes paralelos al eje del clivus en la enfermedad vascular vértebro-basilar / Comparative analysis between digital angiography and MR: special coronal planes paralell to clivus in vertebro-basilar pathology

Se analizan 17 enfermos con patología vascular del sistema vértrebrobasilar que requirieron de angiografía por substracción digital (ASD) y/o resonancia magnética(RM) para su evaluación. Además, en la RM se realizó un nuevo método de cortes paralelos al eje del clivus,para obtener mejores imágenes de los vasos del sistema vértebrobasilar. Los hallazgos obtenidos por RM con la técnica propuesta nos permitieron observar el segmento V4 de las arterias vertebrales en un 82.4%; unión vértebrobasilar 82.4%; arteria basilar proximal 94.1%; arteria basilar medial 76.5%; arteria basilar distal 82.4%y bifurcación basilar 41.2%. Los resultados mostraron que dicha investigación mejora la visualización de las estructuras vasculares del sistema vértebrobasilar comparado con el plano de corte sagital y coronal. Los autores concluyen que el empleo de RM con cortes paralelos al eje del clivus justifica la realización de angiografía por substracción digital (ASD) en ciertos grupos de pacientes.