Duplicate origin of left vertebral artery with thrombosis at the origin: color Doppler sonography and CT angiography findings

Applied anatomy of the vertebral arteries for endovascular neurointerventions

The vertebral arteries (VAs) constitute most of the arterial supply to the posterior cerebral vascular circulation. They have anatomical specificities and may have variants that are critical for neurointerventionists to recognize in order to design open or endovascular surgical treatment. This review addresses each segment of the VA including its origin and discusses the branches and relevant anatomical features for neurointerventions.

Embryology of the vertebral artery and variants of the adult

The vertebral arteries represent in the adult the main blood supply of the posterior cranial fossa, even if they appear relatively late during the embryological life. We reviewed all the most important steps of the vertebral artery's embryological development and the most common variants that can occur in the adult. The aim of this review is to summarize the main events of the development of this artery and to give an embryological explication for the most common variants of this artery.

Dual origin of vertebral artery and intimal relationship with spontaneous artery dissection: a case report and systematic review

Dual origin of the vertebral artery (VA) is an uncommon anatomical variation. We describe a case of duplication origin at right vertebral artery (RVA) found incidentally in one elderly patient on investigation for cerebral aneurysm. Angiogram study showed a pseudoaneurysm at V4 segment of the RVA associated with embryological anatomy. The authors performed a systematic review of the similar cases reported worldwide.

A systematic classification of the vertebral artery variable origin: clinical and surgical implications

Several congenital anomalies regarding the right (RVA) and left (LVA) vertebral artery have been described. The current paper aims to perform a systematic literature review of the variable vertebral artery (VA) origin from the aortic arch (AOA) and its branches. The incidence of these variants and the ensuing AOA branching pattern are highlighted. Atypical origin cases were found more commonly unilaterally, while LVA presented the majority of the aberrancies. The LVA emersion from the AOA (3.6%) and the RVA from the right common carotid artery (RCCA) (0.14%) were the commonest origin variations. Aberrant RVA origin as last branch of the AOA is very rare. Eighteen cases (0.12%) with an aberrant right subclavian artery (ARSCA) were found. Among them, the RVA originated from the RCCA and right subclavian artery in 94.4 and 5.6%, respectively. Sporadic cases had an AOA origin bilaterally; RVA and LVA had a double origin in 0.027 and 0.11%, respectively. A dual origin was detected in 0.0069%, bilaterally. The atypical VA origin may coexist with: (i) an ARSCA, (ii) a common origin of brachiocephalic artery and left common carotid artery (the misnomer bovine arch) and (iii) a bicarotid trunk. The aberrant VA origin favors hemodynamic alterations, predisposing to cerebrovascular disorders and intracranial aneurysm formation. Detailed information of VA variants is crucial for both endovascular interventionists and diagnostic radiologists involved in the treatment of patients with cerebrovascular disease. Such information may prove useful to minimize the risk of VA injury in several procedures.

Duplicated Vertebral Artery : Literature Review and Clinical Significance

Objective

Duplication of the vertebral artery (VA) is a rare vascular variant. This paper describes the anatomy and embryological development of duplicated VAs and reviews the clinical significance.

Methods

Computed tomography (CT) angiography was performed in 3386 patients (1880 females, 1506 males) between March 2014 and November 2015. We defined duplication of the VA as a condition in which the VA has two origins that fused at different levels of the neck.

Results

Ten of the 3386 patients (0.295%) who received CT angiography had a dual origin of the VA; three on the left side, and seven on the right side. In all seven with right dual origin of the VA, both limbs of the VA origin originated from the right subclavian artery. In all three patients with left dual origin of the VA, both limbs of the VA originated from the left subclavian artery and aortic arch. In all 10 patients, the medial limb of the duplicated VA was located posteriorly and medially to the common carotid artery (CCA) and anteriorly and laterally to the vertebral transverse foramen. In two patients, the medial limb of the duplicated VA was located in close proximity to the CCA. In another two patients, the medial limb of the duplicated VA was located in close proximity to the CCA, carotid bifurcation, and proximal internal carotid artery.

Conclusion

Although duplication of the VA is asymptomatic in most patients, clinicians should consider this anomaly during diagnosis and treatment.

Aberrant Origin of Vertebral Artery and its Clinical Implications

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.

Duplication of the right vertebral artery: MRA findings and review of the literature

Introduction

Duplication of the vertebral artery (VA) is a rare vascular variant. To the best our knowledge, only fourteen cases have been reported with angiographic findings that they have dual origin of the VA from ipsilateral subclavian artery. Herein, we present a case of duplication of right VA which was incidentally detected by magnetic resonance (MR) angiography.

Case description

A 69-year-old female patient presented with headache for 30 days. She underwent brain MR imaging with MR angiography for evaluating possible intracranial cause. There was a dual origin of the right vertebral artery (VA) as an incidental finding without other significant abnormalities.

Discussion and Evaluation

Diagnosis of duplicated VA can be difficult due to its rarity and misinterpreted as the vascular dissection. In addition, a detailed knowledge of this variation is potentially important to prevent inadvertent challenges during endovascular procedure. Because duplicated VA has smaller lumen and usually enters the higher transverse foramen than those of normal side, it can be influence the choice or route of endovascular treatment.

Conclusions

We suggested that the understanding of embryologic background about VA can be helpful to identify unexpected vascular findings on imaging studies in clinical practice.

Fenestration and duplication of the vertebral artery: the anatomical and clinical points of view

The vertebral artery (VA) acts as a foundation for the posterior circulation of the head and neck. It presents a number of anomalies that can be easily visualized thanks to modern imaging techniques, such as MR and CT angiography or color Doppler ulrasonography. Determining the appropriate terminology for those anomalies can be sometimes more challenging than their recognition. One particular challenge concerns the differentiation between VA fenestration and duplication. Because of the different clinical prognoses associated with those anomalies, confusion should be avoided. Knowledge of the morphological anomalies associated with the VA is important for both radiologists and head and neck surgeons, because any injury to the VA can result in a threat to the vascular supply of the brain stem, the cerebral or cerebellar hemispheres, the thalamus, cervical nerve roots and particularly the lateral medulla (Wallenberg's syndrome). This article analyses world literature concerning the issue of VA fenestration and duplication to facilitate a differential diagnosis.

Duplication of the left vertebral artery in a patient with dissection of the right internal carotid artery and Ehlers-Danlos syndrome: case report and review of the literature

Duplication of the left vertebral artery was observed in a 43-year-old Caucasian male with dissection of the right internal carotid artery during multidetector 64-row computer tomography and Doppler ultrasonography B-flow mode. Both duplicated segments arose from the left subclavian artery and united at levels C5–C6 to form a single vessel. The presented case describes precisely the origin and diameter of both vertebral arteries. Additionally, after all procedures associated with diagnosis and treatment of the patient, Ehlers–Danlos syndrome type IV was diagnosed. The lumen of the duplicated vertebral artery was smaller than normal; it can be concluded that this variant has clinical implications and should be taken into consideration when vertebral arteries need catheterization.

Dual origin of the left vertebral artery: extracranial MRA and CTA findings

A 48-year-old man presented with a posterior circulation stroke secondary to left lateral medullary infarction. Contrast-enhanced magnetic resonance angiography (CEMRA) revealed 40-45% intracranial left vertebral artery stenosis, likely atherosclerotic in nature. CEMRA and subsequent computed tomography angiography also identified a duplicate origin of the left vertebral artery. The importance of recognition of this rare anatomical variant, its potential contribution to stroke aetiology, and the advantage of non-invasive vascular imaging prior to catheter angiography is emphasised.