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Hu Z, Ban J, Li Z, Yang D, Li K, Zhang X, Hu F, Li Q, Mao W, Liang Y, Luo D, Chen Z, Chen H, Shi Y. An analysis of clinical characteristics of rare bilateral medial medullary infarction: An observational study. Medicine (Baltimore) 2024; 103:e38336. [PMID: 38905383 PMCID: PMC11191992 DOI: 10.1097/md.0000000000038336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/02/2024] [Indexed: 06/23/2024] Open
Abstract
This study aimed to characterize the risk factors, etiology, clinical manifestations, anatomical characteristics, stroke mechanisms, imaging features, and prognosis of bilateral medial medullary infarction (BMMI). A retrospective analysis was conducted on 11 patients with BMMI who met the inclusion criteria at the Affiliated Hospital of Xuzhou Medical University from January 2013 to January 2023. The patients' imaging and clinical features were analyzed and summarized. Eleven patients (7 male, 4 female), aged 46 to 62 years, met the inclusion criteria. Common clinical presentations included dysarthria (90.9%), dysphagia (90.9%), quadriplegia (81.8%), and so on. Within 72 hours of onset, 8 cases presented with quadriplegia, 2 cases with hemiplegia, and 1 case without limb paralysis. The main risk factor for BMMI was hypertension, followed by diabetes. "Heart appearance" infarcts occurred in 4 cases (36.4%), while "Y appearance" infarcts occurred in 7 cases (63.6%). Among the patients, 3 had unilateral vertebral artery stenosis or occlusion, 5 had bilateral vertebral artery stenosis or occlusion, 2 had normal vertebral basilar artery, and 1 did not undergo cerebrovascular examination. All patients received standardized treatment for cerebral infarction. The prognosis was poor, with 81.8% of patients having an unfavorable outcome, including 1 death, 9 cases of disability, and only 1 patient achieving self-care ability after recovery. BMMI is more prevalent in males aged 45 to 60 years. The main risk factors are hypertension and diabetes. Atherosclerosis is the primary etiological subtype. The main clinical manifestations are dyskinesia, dizziness, quadriplegia, and dysarthria. The prognosis of BMMI is poor. The specific imaging features of "heart appearance" or "Y appearance" infarcts aid in the diagnosis of BMMI.
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Affiliation(s)
- Zhenzhu Hu
- Department of Neurology, XuZhou New Healthy Geriatric Hospital, Xuzhou, Jiangsu, China
| | - Jin Ban
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Zhaoying Li
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dongdong Yang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ke Li
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xuanchao Zhang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Fangfang Hu
- Department of Neurology, Xuzhou Cancer Hospital, Xuzhou, Jiangsu, China
| | - Qingqing Li
- Department of Neurology, Xuzhou Cancer Hospital, Xuzhou, Jiangsu, China
| | - Wenqi Mao
- Department of Neurology, XuZhou New Healthy Geriatric Hospital, Xuzhou, Jiangsu, China
| | - Yanjing Liang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dehua Luo
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhenwei Chen
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hao Chen
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yu Shi
- Department of Neurology, Xuzhou Cancer Hospital, Xuzhou, Jiangsu, China
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Chaalala C, El Hage G, Gilbert V, Martin T, Iancu D, Labidi M, Bojanowski MW. Spontaneous intracranial vertebral artery dissections presenting with subarachnoid hemorrhage. Neurochirurgie 2024; 70:101526. [PMID: 38277864 DOI: 10.1016/j.neuchi.2023.101526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Vertebral artery dissection (VAD) is an infrequent source of subarachnoid hemorrhage (SAH), with a high mortality rate, primarily due to the risk of rebleeding both before and after medical intervention. This paper provides a comprehensive analysis of the anatomy, pathophysiology, clinical presentation, treatment strategies, and outcomes of intracranial vertebral artery dissections that result in subarachnoid hemorrhage. METHODS Comprehensive five-year literature review (2018-2022) and a retrospective analysis of patient records from our institution between 2016 and 2022. We included studies with a minimum of 5 patients. RESULTS The study incorporated ten series from the literature and 22 cases from CHUM. Key anatomical factors increasing the risk of VAD include the vertebral artery's origin from the aortic arch, asymmetry of the vertebral artery, and its tortuosity. Patients may display specific collagen and genetic abnormalities. The occurrence of VAD appears to be more prevalent in men. Those with a ruptured intracranial VAD typically show prodromal symptoms and present with severe SAH. Rebleeding within the first 24 h is frequent. While standard imaging methods are usually adequate for VAD diagnosis, they may not provide detailed information about the perforator anatomy. Treatment approaches include both deconstructive and reconstructive methods. CONCLUSION Ruptured VAD is a critical, life-threatening condition. Many patients have a poor neurological status at presentation, and rebleeding prior to treatment is a significant concern. Deconstructive techniques are most effective in preventing rebleeding, whereas the efficacy of reconstructive techniques needs more investigation.
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Affiliation(s)
- Chiraz Chaalala
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada.
| | - Gilles El Hage
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Valérie Gilbert
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Tristan Martin
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Daniela Iancu
- Division of Neuroradiology, Radiology Department, University of Montreal, Quebec, Canada
| | - Moujahed Labidi
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
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Jadhav AP. Vascular Myelopathies. Continuum (Minneap Minn) 2024; 30:160-179. [PMID: 38330477 DOI: 10.1212/con.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. LATEST DEVELOPMENTS Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. ESSENTIAL POINTS Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.
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Shima S, Ryu B, Sato S, Mochizuki T, Inoue T, Niimi Y. FLOW-diverted Glue Embolization to Target lesions (FLOW-GET) technique for spinal vascular diseases: A technical note. J Neuroradiol 2023; 50:505-510. [PMID: 36967047 DOI: 10.1016/j.neurad.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023]
Abstract
We present and exemplify the flow-diverted glue embolization to target lesions (FLOW-GET) technique for spinal vascular diseases. In this technique, the occlusion of the posterior intercostal artery or dorsal muscular branch by coils diverts the injected glue from the segmental artery to the target lesions. This technique was applied to a ruptured retrocorporeal artery aneurysm and spinal dural arteriovenous fistulas. The FLOW-GET accomplished the complete obliteration of all lesions. This simple and useful technique can be applied to spinal vascular lesions even if a microcatheter is not placed in proper feeders or advanced close to the shunt points or aneurysms.
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Affiliation(s)
- Shogo Shima
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan.
| | - Bikei Ryu
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
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Djukić B, Djukić-Macut N, Djulejić V, Boljanović J, Milić I, Marinković S, Blagojević M. Medullary branches of the vertebral artery: microsurgical anatomy and clinical significance. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05613-7. [PMID: 37162608 DOI: 10.1007/s00701-023-05613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Since the medullary arteries are of a great neurologic and neurosurgical significance, the aim was to perform a detailed microanatomic study of these vessels, as well as of the medullary infarctions in a group of patients. METHODS The arteries of 26 halves of the brain stem were injected with India ink and gelatin, microdissected and measured with an ocular micrometer. Neurologic and magnetic resonance imaging (MRI) examinations were performed in 11 patients. RESULTS The perforating medullary arteries, averaging 6.7 in number and 0.26 mm in diameter, most often originated from the anterior spinal artery (ASA), and rarely from the vertebral (VA) (38.5%) and the basilar artery (BA) (11.6%). They supplied the medial medullary region. The anterolateral arteries, 4.8 in number and 0.2 mm in size, most often arose from the ASA and PerfAs, and nourished the anterolateral region. The lateral arteries, 2.2 in number and 0.31 mm in diameter, usually originated from the VA and the posterior inferior cerebellar artery (PICA). They supplied the lateral medullary region. The dorsal arteries, which mainly arose from the PICA and the posterior spinal artery (PSA), nourished the dorsal region, including the roof of the 4th ventricle. The anastomotic channels, averaging 0.3 mm in size, were noted in 42.3%. Among the medullary infarctions, the lateral ones were most frequently present (72.8%). CONCLUSION The obtained anatomic data, which can explain the medullary infarctions symptomatology, are also important in order to avoid damage to the medullary arteries during neurosurgical and neuroradiologic interventions.
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Affiliation(s)
- Bojana Djukić
- Department of Neuroscience, Institute of Medical Research, University of Belgrade, Belgrade, Serbia
| | - Nataša Djukić-Macut
- Seat in Mitrovica, Faculty of Medicine, University of Prishtina, Mitrovica, Serbia
| | - Vuk Djulejić
- Faculty of Medicine, Institute of Anatomy, University of Belgrade, Dr. Subotić, 4/2, 11000, Belgrade, Serbia
| | - Jelena Boljanović
- Faculty of Medicine, Institute of Anatomy, University of Belgrade, Dr. Subotić, 4/2, 11000, Belgrade, Serbia
| | - Ivan Milić
- Faculty of Medicine, Clinic of Neurosurgery, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Slobodan Marinković
- Faculty of Medicine, Institute of Anatomy, University of Belgrade, Dr. Subotić, 4/2, 11000, Belgrade, Serbia.
| | - Miloš Blagojević
- Faculty of Veterinary Medicine, Institute of Anatomy, University of Belgrade, Belgrade, Serbia
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Parra JED, Ríos JB, García JFV. Variations in the origin of the anterior spinal artery in a Colombian population sample. Anat Cell Biol 2022; 55:520-524. [PMID: 36316283 PMCID: PMC9747338 DOI: 10.5115/acb.22.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/19/2022] [Accepted: 10/04/2022] [Indexed: 12/13/2022] Open
Abstract
Based on most neuroanatomical descriptions, the anterior spinal artery (ASA) originates from two small vessels of the vertebral arteries, which are anastomosed just before forming the basilar artery. This study aimed to determine and quantify the possible variants of the origin of the ASA and its trajectory in samples of human brain stems. Male brain stems with the superior portion of the spinal cord until myelomera C3 of 23 adult human, and no evident morphological alterations were selected. The brain stems were collected for three years and fixed in a 10% formalin solution at the Anatomy Laboratory of the Universidad de Caldas (Colombia). Five samples (21.7%) had variations in the origin and trajectory of the anterior spinal artery. The variations in the origin of the ASA could generate morphofunctional advantages instead of leading to complications. That is the case when there are two anterior spinal arteries since it would increase tissue perfusion, thus protecting part of the spinal cord from ischemic pathologies. It is essential to consider the variations that may exist in the supply of the anterior region of the spinal cord for clinical and surgical assessments due to variations in its supplied territory.
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Affiliation(s)
- Jorge Eduardo Duque Parra
- Department of Basic Sciences, Program of Medicine, Universidad de Caldas, Manizales, Colombia,Department of Basic Sciences, Program of Medicine, Universidad de Manizales, Manizales, Colombia
| | - John Barco Ríos
- Department of Basic Sciences, Program of Medicine, Universidad de Caldas, Manizales, Colombia
| | - Juan Fernando Vélez García
- Department of Animal Health, Faculty of Veterinary Medicine and Zootechnics, Universidad del Tolima, Ibagué, Colombia,Corresponding author: Juan Fernando Vélez García, Department of Animal Health, Faculty of Veterinary Medicine and Zootechnics, Universidad del Tolima, Ibagué 730006299, Colombia, E-mail:
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7
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Entwistle JW, Drake DH, Fenton KN, Smith MA, Sade RM. Normothermic Regional Perfusion: Ethical Issues in Thoracic Organ Donation. Ann Thorac Surg 2022; 114:44-51. [PMID: 35589419 DOI: 10.1016/j.athoracsur.2022.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John W Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Michael A Smith
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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8
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Entwistle JW, Drake DH, Fenton KN, Smith MA, Sade RM. Normothermic regional perfusion: Ethical issues in thoracic organ donation. J Thorac Cardiovasc Surg 2022; 164:147-154. [PMID: 35369998 DOI: 10.1016/j.jtcvs.2022.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/20/2023]
Affiliation(s)
- John W Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | | | - Michael A Smith
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
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Du K, Feng X, Xie H, Wu W. To Inadvertent Vascular Placement of an Intrathecal Catheter: A Case Report. A A Pract 2022; 16:e01557. [PMID: 35050904 DOI: 10.1213/xaa.0000000000001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intrathecal drug delivery systems (IDDS) are a treatment option for patients with chronic nonmalignant pain and cancer pain. In this case report, we describe a patient in whom an intrathecal catheter was implanted into a blood vessel rather than into the subarachnoid cavity. A contrast agent was administered, and digital subtraction angiography (DSA) imaging suggested that the catheter was inserted into a blood vessel. The anterior spinal arteries and veins were verified on the ventral side of the spinal cord without interruption. To our knowledge, this is the first report of implantation of an IDDS catheter into a blood vessel.
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Affiliation(s)
- Kairong Du
- From the Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
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Nuñez M, Guillotte A, Faraji AH, Deng H, Goldschmidt E. Blood supply to the corticospinal tract: A pictorial review with application to cranial surgery and stroke. Clin Anat 2021; 34:1224-1232. [PMID: 34478213 DOI: 10.1002/ca.23782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022]
Abstract
The corticospinal tract (CST) is the main neural pathway responsible for conducting voluntary motor function in the central nervous system. The CST condenses into fiber bundles as it descends from the frontoparietal cortex, traveling down to terminate at the anterior horn of the spinal cord. The CST is at risk of injury from vascular insult from strokes and during neurosurgical procedures. The aim of this article is to identify and describe the vasculature associated with the CST from the cortex to the medulla. Dissection of cadaveric specimens was carried out in a manner, which exposed and preserved the fiber tracts of the CST, as well as the arterial systems that supply them. At the level of the motor cortex, the CST is supplied by terminal branches of the anterior cerebral artery and middle cerebral artery. The white matter tracts of the corona radiata and internal capsule are supplied by small perforators including the lenticulostriate arteries and branches of the anterior choroidal artery. In the brainstem, the CST is supplied by anterior perforating branches from the basilar and vertebral arteries. The caudal portions of the CST in the medulla are supplied by the anterior spinal artery, which branches from the vertebral arteries. The non-anastomotic nature of the vessel systems of the CST highlights the importance of their preservation during neurosurgical procedures. Anatomical knowledge of the CST is paramount to clinical diagnosis and treatment of heterogeneity of neurodegenerative, neuroinflammatory, cerebrovascular, and skull base tumors.
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Affiliation(s)
- Maximilano Nuñez
- Hospital El Cruce, Buenos Aires University Medical School, Florencio Varela, Argentina
| | - Andrew Guillotte
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ezequiel Goldschmidt
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Genkai N, Okamoto K, Nomura T, Abe H. Endovascular treatment of a ruptured aneurysm arising from the proximal end of a partial vertebrobasilar duplication with a contralateral prominent persistent primitive hypoglossal artery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20108. [PMID: 35854835 PMCID: PMC9245766 DOI: 10.3171/case20108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ruptured aneurysms associated with a partial vertebrobasilar duplication or a persistent primitive hypoglossal artery (PPHA) have been reported. Only rarely has endovascular treatment of ruptured aneurysms in association with both vascular variations been reported. OBSERVATIONS A 66-year-old woman experienced the sudden onset of a severe headache caused by a subarachnoid hemorrhage. Cerebral angiograms demonstrated a prominent PPHA originating from the left internal carotid artery at the C2 vertebral level and a partial vertebrobasilar duplication between the hypoplastic right vertebral artery and proximal basilar artery with a small aneurysm at the proximal end of the duplication from where the anterior spinal artery originated. The left vertebral artery was aplastic. A microcatheter was introduced into the aneurysm via the PPHA under the control of high blood flow, using a balloon-assisted technique. The aneurysm was completely obliterated with a coil. Although small cerebellar and cerebral infarcts developed during the procedure, the patient was discharged without neurological symptoms. LESSONS To avoid serious neurological complications, precise analysis of the complex vascular anatomy, including the anterior spinal artery and hemodynamics, is clinically important for endovascular therapy of cerebral aneurysms in patients with an association between a partial vertebrobasilar duplication and a PPHA.
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Affiliation(s)
- Nobuyuki Genkai
- Department of Neurosurgery, Tachikawa General Hospital, Tachikawa Medical Center, Niigata, Japan; and
| | - Kouichirou Okamoto
- Department of Translational Research, Brain Research Institute, Niigata University, Niigata, Japan
| | - Toshiharu Nomura
- Department of Neurosurgery, Tachikawa General Hospital, Tachikawa Medical Center, Niigata, Japan; and
| | - Hiroshi Abe
- Department of Neurosurgery, Tachikawa General Hospital, Tachikawa Medical Center, Niigata, Japan; and
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Dmytriw AA, Kapadia A, Enriquez-Marulanda A, Parra-Fariñas C, Kühn AL, Nicholson PJ, Waqas M, Renieri L, Michelozzi C, Foreman PM, Phan K, Yang IH, Tutino VM, Ogilvy CS, Radovanovic I, Harrigan MR, Siddiqui AH, Levy EI, Limbucci N, Cognard C, Krings T, Pereira VM, Thomas AJ, Marotta TR, Griessenauer CJ. Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion. J Neurosurg 2020; 134:961-970. [PMID: 32217800 DOI: 10.3171/2020.1.jns193293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Coverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction. METHODS A multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome. RESULTS Sixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage. CONCLUSIONS FD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.
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Affiliation(s)
- Adam A Dmytriw
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto.,2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anish Kapadia
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto.,2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Alejandro Enriquez-Marulanda
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carmen Parra-Fariñas
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Anna Luisa Kühn
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Patrick J Nicholson
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Muhammad Waqas
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Leonardo Renieri
- 6Department of Interventional Neuroradiology, University of Florence, Italy
| | | | - Paul M Foreman
- 4Orlando Health, Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Kevin Phan
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - I-Hsiao Yang
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,8Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Vincent M Tutino
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Christopher S Ogilvy
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Ivan Radovanovic
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mark R Harrigan
- 7Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Adnan H Siddiqui
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Elad I Levy
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Nicola Limbucci
- 6Department of Interventional Neuroradiology, University of Florence, Italy
| | - Christophe Cognard
- 9Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Timo Krings
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vitor Mendes Pereira
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Thomas R Marotta
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- 10Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania; and.,11Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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Ravina K, Strickland BA, Rennert RC, Fredrickson V, Bakhsheshian J, Chien M, Mack W, Amar A, Russin JJ. Fusiform vertebral artery aneurysms involving the posterior inferior cerebellar artery origin associated with the sole angiographic anterior spinal artery origin: technical case report and treatment paradigm proposal. J Neurosurg 2018; 131:1324-1330. [PMID: 30485231 DOI: 10.3171/2018.5.jns18681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
Fusiform aneurysms of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA) origin are uncommon and challenging. The anterior spinal artery (ASA) commonly originates from a unilateral ramus just distal to the PICA. Occlusion of an unpaired ASA can result in bilateral medial medullary syndrome. The authors propose a treatment paradigm for ASA preservation based on the artery's proximity to fusiform VA aneurysms, and they present 3 representative cases. In the first case, they performed a V3-PICA bypass using an interposition graft and then performed endovascular coil embolization of the parent VA. A complete occlusion of the aneurysm and VA was complicated by ASA thrombosis. The subsequent cases were treated with PICA-PICA bypass and subsequent endovascular embolization of the VA. Filling of the sole angiographic ASA remote from the aneurysm was preserved in both cases. The anatomy of the ASA is the most critical determinant of treatment recommendations for fusiform VA aneurysms involving PICA. When the ASA originates from the aneurysm, proximal occlusion with or without a PICA bypass is suggested. In cases in which the ASA is removed from the aneurysm, the authors recommend revascularization followed by endovascular sacrifice. When the aneurysm is immediately adjacent to the ASA, revascularization and open trapping should be considered.
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Affiliation(s)
| | - Ben A Strickland
- 2Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
| | - Robert C Rennert
- 3Department of Neurosurgery, University of California, San Diego, California
| | - Vance Fredrickson
- 2Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
| | - Joshua Bakhsheshian
- 2Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
| | - Mark Chien
- 1Neurorestoration Center, Keck School of Medicine and
| | - William Mack
- 2Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
| | - Arun Amar
- 2Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
| | - Jonathan J Russin
- 1Neurorestoration Center, Keck School of Medicine and
- 2Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
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