Microsurgical treatment of vertebral artery dissection: Surgical strategies and treatment outcomes

High-resolution magnetic resonance imaging in the diagnosis and management of vertebral artery dissection: A case report

BACKGROUND

Vertebral artery dissection (VAD) is a rare but life-threatening condition characterized by tearing of the intimal layer of the vertebral artery, leading to stenosis, occlusion or rupture. The clinical presentation of VAD can be heterogeneous, with common symptoms including headache, dizziness and balance problems. Timely diagnosis and treatment are crucial for favorable outcomes; however, VAD is often missed due to its variable clinical presentation and lack of robust diagnostic guidelines. High-resolution magnetic resonance imaging (HRMRI) has emerged as a reliable diagnostic tool for VAD, providing detailed visualization of vessel wall abnormalities.

CASE SUMMARY

A young male patient presented with an acute onset of severe headache, vomiting, and seizures, followed by altered consciousness. Imaging studies revealed bilateral VAD, basilar artery thrombosis, multiple brainstem and cerebellar infarcts, and subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed vertebral artery stenosis but failed to detect the dissection, potentially because intramural thrombosis obscured the VAD. In contrast, HRMRI confirmed the diagnosis by revealing specific signs of dissection. The patient was managed conservatively with antiplatelet therapy and other supportive measures, such as blood pressure control and pain management. After 5 mo of rehabilitation, the patient showed significant improvement in swallowing and limb strength.

CONCLUSION

HR-MRI can provide precise evidence for the identification of VAD.

Spontaneous Bilateral Vertebral Artery Dissection as a Rare Cause of Posterior Circulation Stroke in a Young Patient

In young patients, ischemic stroke is an uncommon result of vertebral artery dissection (VAD). Damage to the vertebrae can occur suddenly or as a result of trauma. There are no generally recognized recommendations for diagnosis and treatment, and the majority of vague symptoms and delayed presentation provide a significant diagnostic problem. While medical management with anticoagulant or antiplatelet therapy is advised, no successful dual therapy has been documented. Although traumatic dissection is a more frequent cause of posterior cerebral circulation stroke in people under 45 years of age than spontaneous dissection, spontaneous VAD is well-reported and usually treated with anticoagulation. VAD can result in fatal complications such as basilar area infarction, even though it is often asymptomatic. Here is a case of a 37-year-old male who presented with a posterior circulation stroke after bilateral VAD with no evidence of trauma to the neck and no detectable cause suggesting spontaneous etiology.

Surgical management of tumors of the cervical spine and craniovertebral junction involving the vertebral artery: A narrative review

BACKGROUND

The vertebral artery (VA) is in close proximity to bony structures, nerves and nerve sheaths of the cervical spine and craniovertebral junction (CVJ). These structures can be sources of tumors that are responsible for displacement, encasement and sometimes invasion of the VA. Removing these tumors while minimizing the risk of vascular injury requires thorough knowledge of the vascular anatomy, risk factors of vascular injury, the relationships of each tumor type with the VA, and the different surgical approaches and techniques that result in the best outcomes in terms of vascular control, tumoral exposure and resection.

OBJECTIVE

To present an overview of preoperative and anatomical considerations, differential diagnoses and various approaches to consider in cases of tumors in close relationship with the VA.

METHOD

A review of recent literature was conducted to examine the anatomy of the VA, the tumors most frequently affecting it, surgical approaches, and the necessary pre-operative preparations for ensuring safe and maximal tumor resection. This review aims to underscore the principles of treatment.

CONCLUSION

Tumors located at the CVJ and the cervical spine intimately involved with the VA, pose a surgical challenge and increase the risk of incomplete removal of the lesion. Detailed knowledge of the patient-specific anatomy and a targeted pre-operative work-up enable optimal planning of surgical approach and management of the VA, thereby reducing surgical risks and improving extent of resection.

Cerebral revascularization for complex vertebrobasilar artery dissecting aneurysms

Vertebrobasilar artery dissecting aneurysms (VBDAs) are the most surgically challenging type of aneurysm. Cerebral revascularization is the ultimate treatment for complex VBDAs. We retrospectively analysed the characteristics, surgical outcomes and follow-up data of 21 patients who underwent cerebral revascularization to treat complex VBDAs from 2015 to 2022. According to the location of the aneurysm and the anatomic relationship between the VBDA and the PICA, VBDA patients were classified into four groups: aneurysms located at the VA with PICA involvement (10 patients), aneurysms located at the VA without PICA involvement (1 patient), aneurysms located at the basilar apex segment (1 patient) and aneurysms located at the basilar trunk segment (9 patients). A surgical algorithm for complex VBDAs was determined primarily by the location of the aneurysm, the status of the aneurysm and the ability of retrograde blood flow to reach the proximal vertebrobasilar artery. Surgical modalities for patients with aneurysms in the VA with PICA involvement included low-flow (OA-PICA) bypasses with aneurysm trapping, aneurysm excision or reconstructive clip in 8 patients and STA-PCA bypass combined with PICA preservation and aneurysm trapping in 2 patients. In patients with aneurysms in the VA without PICA involvement, aneurysm excision was performed without cerebral bypass. In patients with aneurysms in the basilar apex segment, high-flow bypass (ECA-RA-P2) with aneurysm trapping was performed. In patients with aneurysms in the basilar trunk segment, surgical modalities included high-flow bypasses (ECA-RA-P2 and LVA-RA-P2) with aneurysm trapping or proximal occlusion in 6 patients, ECA-RA-P2 bypass with partial proximal occlusion in 1 patient, ECA-RA-P2 bypass alone in 1 patient, and STA-PCA bypass with R-VA narrowing in 1 patient. Of the 21 patients, 20 experienced clinical improvement or no change, and 17 of 21 patients achieved favourable functional outcomes (mRS ≤ 2). However, one patient died of infarction and respiratory failure postoperatively. Aneurysms were completely obliterated in 13 patients, shrank in 5 patients and stabilized in 2 patients. The median follow-up period was 32.5 months. During the follow-up period, all bypasses were patent, and further clinical improvement was observed in 11 patients. Cerebral revascularization appears to be safe and effective for the treatment of complex VBDAs, and cerebral revascularization could act as a complementary treatment strategy.

Microsurgical partial trapping for the treatment of unclippable vertebral artery aneurysms: Experience from 27 patients and review of literature

BACKGROUND

The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications.

METHODS

This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated.

RESULTS

Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall.

CONCLUSIONS

Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs.

Hemifacial spasm caused by unruptured fusiform vertebral aneurysm treated with endovascular coil embolization: a case report

Hemifacial spasm due to fusiform aneurysm of the vertebral artery is extremely rare. The lateral spread response (LSR) is routinely used to monitor hemifacial spasms during microvascular decompression to predict the degree of postoperative remission of hemifacial spasm. We report a case of hemifacial spasm caused by an unruptured fusiform vertebral aneurysm treated with intravascular intervention and monitoring of LSR. A 59-year-old man was admitted to the hospital with a left facial spasm that gradually worsened for 1 year. Preoperative cerebrovascular angiography indicated fusiform aneurysms in the intracranial segment of the left vertebral artery close to the left facial nerve. The patient underwent parent artery occlusion and aneurysm embolization, and LSR was monitored intraoperatively. After intraoperative aneurysm embolization, LSR disappeared immediately. The postoperative review of cerebrovascular angiography indicated that the parent artery and aneurysm were embolized successfully, and the patient's left facial spasm was relieved after surgery. Hemifacial spasm caused by the vertebral artery fusiform aneurysm can be safely and effectively treated by parent artery occlusion and aneurysm embolization. Meanwhile, intraoperative LSR monitoring can be used to predict postoperative efficacy.

Far-lateral approach without C1 laminectomy for microsurgical treatment of vertebral artery and proximal posterior inferior cerebellar artery aneurysms: Experience from 48 patients

Background

In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes.

Methods

Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated.

Results

Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA-PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively.

Conclusions

Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.