Vertebral artery dissection

Treatable Ataxias: How to Find the Needle in the Haystack?

Treatable ataxias are a group of ataxic disorders with specific treatments. These disorders include genetic and metabolic disorders, immune-mediated ataxic disorders, and ataxic disorders associated with infectious and parainfectious etiology, vascular causes, toxins and chemicals, and endocrinopathies. This review provides a comprehensive overview of different treatable ataxias. The major metabolic and genetic treatable ataxic disorders include ataxia with vitamin E deficiency, abetalipoproteinemia, cerebrotendinous xanthomatosis, Niemann-Pick disease type C, autosomal recessive cerebellar ataxia due to coenzyme Q10 deficiency, glucose transporter type 1 deficiency, and episodic ataxia type 2. The treatment of these disorders includes the replacement of deficient cofactors and vitamins, dietary modifications, and other specific treatments. Treatable ataxias with immune-mediated etiologies include gluten ataxia, anti-glutamic acid decarboxylase antibody-associated ataxia, steroid-responsive encephalopathy associated with autoimmune thyroiditis, Miller-Fisher syndrome, multiple sclerosis, and paraneoplastic cerebellar degeneration. Although dietary modification with a gluten-free diet is adequate in gluten ataxia, other autoimmune ataxias are managed by short-course steroids, plasma exchange, or immunomodulation. For autoimmune ataxias secondary to malignancy, treatment of tumor can reduce ataxic symptoms. Chronic alcohol consumption, antiepileptics, anticancer drugs, exposure to insecticides, heavy metals, and recreational drugs are potentially avoidable and treatable causes of ataxia. Infective and parainfectious causes of cerebellar ataxias include acute cerebellitis, postinfectious ataxia, Whipple's disease, meningoencephalitis, and progressive multifocal leukoencephalopathy. These disorders are treated with steroids and antibiotics. Recognizing treatable disorders is of paramount importance when dealing with ataxias given that early treatment can prevent permanent neurological sequelae.

Endovascular Management of Intracranial Vertebral Artery Dissection: Technical Nuances for the Preservation of Posterior Inferior Cerebellar Artery and Basilar Artery

BACKGROUND

The treatment of intracranial vertebral artery dissection (VAD) can be challenging.

OBJECTIVE

To evaluate the clinical presentation, endovascular treatment techniques, and prognostic outcome of patients diagnosed with intracranial VAD at our institution.

METHODS

A retrospective analysis of 35 patients who were diagnosed with VAD at our institution over 17-yr period (2001-2017) is presented. A total of 27 patients with a total of 30 affected arteries underwent endovascular treatment, and their outcome was evaluated.

RESULTS

Of the 35 total patients with VAD, 15 presented with headache, 12 with focal neurological deficits, 2 with neck pain, 2 with dizziness, 1 with syncope, and 3 after trauma. Of the 30 dissected arteries, 18 were treated with deconstruction and 12 were treated with stent reconstruction. Treatment method was determined by the dominance of the affected artery and location relative to the ipsilateral posterior inferior cerebellar artery (PICA) and the basilar artery. Deconstructive techniques were utilized in all cases of hypoplastic artery dissection and the majority of codominant artery dissections, whereas reconstruction was performed on the majority of dominant artery dissections. Rupture did not impact treatment technique. Four patients demonstrated post-treatment infarcts, and another 1 patient died because of intraparenchymal bleed. The remaining 22 patients demonstrated favorable clinical outcome. None of the patients developed recanalization or needed retreatment till the last follow-up.

CONCLUSION

This study suggests that endovascular treatment of intracranial VAD with deconstruction or stent reconstruction based on the patients anatomy, particularly vessel dominance and location with respect to PICA, is feasible and effective though the revascularization procedures still has its role in selected cases.

A Case of Delayed Traumatic Vertebral Artery Dissection

Vertebral artery dissection is of special clinical importance because of its often-delayed presentation and the risk of potentially permanent neurological deficit, or even death, as a result of injury. Once a rarely discovered injury, the better availability and use of computed tomography and magnetic resonance imaging have contributed to an increased incidence. Early diagnosis and treatment can almost eliminate the threat of acute cerebral vascular injury and save lives. In this report, we review a case of delayed traumatic vertebral artery dissection and discuss the key clinical findings and management strategies.

Traumatic vertebral artery injury: proposal for classification of the severity of trauma and likelihood of fatal outcome

Vertebral artery injury (VAI) occurs after (blunt) trauma as well as spontaneously. The risk of incurring VAI from a blunt trauma probably parallels the severity of trauma, often referred to as major- and minor-trauma. However, the literature does not provide concrete definitions of these terms. This study aims to define minor- and major-trauma and to analyze the likelihood of fatal outcome in VAI. For this purpose, classification criteria of major- and minor-trauma were developed and a PubMed database search was performed for articles on VAI published prior to 2013. The definitions of minor- and major-trauma, derived mainly from radiological screening criteria in cervical spine injury and based on the mechanism leading to the injury, were used in the analysis of the literature. The search produced 241 VAI cases with sufficiently detailed data for the comparison of major-trauma (52 cases, 50 lethal), minor-trauma (8 cases, none lethal), and no-trauma (182 cases, 69 lethal). The numbers of lethal cases in the total study population and subgroups differed significantly between the groups (Fisher's exact test) and the likelihood ratios (LRs) of lethal outcome were substantially higher in the major-trauma group compared to the other groups. The highly significant p values show that the proposed criteria differentiate between trauma types with regard to fatal outcome. The presented results can assist in the evaluation of forensic cases of VAI.

Spontaneous atraumatic vertebral artery occlusion due to physiological cervical extension: case report

Vertebral artery (VA) occlusion is a serious and potentially life-threatening occurrence. Bow hunter's syndrome, a mechanical occlusion of the VA due to physiological head rotation, has been well described in the medical literature. However, mechanical VA compression due to routine flexion or extension of the neck has not been previously reported. The authors present the unique case of a woman without any history of trauma who had multiple posterior fossa strokes and was found to have dynamic occlusion of her right VA visualized via cerebral angiogram upon extension of her neck. This occlusion was attributed to instability at the occipitocervical junction in a patient with a previously unknown congenital fusion of both the occiput to C-1 and C-2 to C-3. An occiput to C-3 fusion was performed to stabilize her cervical spine and minimize the dynamic vascular compression. A postoperative angiogram showed no evidence of restricted flow with flexion or extension of the neck. This case emphasizes the importance of considering symptoms of vertebrobasilar insufficiency as a result of physiological head movement. The authors also review the literature on VA compression resulting from physiological head movement as well as strategies for clinical diagnosis and treatment.

Rotational vertebral artery occlusion-series of 9 cases

BACKGROUND

Rotational vertebral artery syndrome (RVAS) is a rare entity about which previously published studies are mostly limited to individual case reports.

OBJECTIVE

To report our decade-long experience with this syndrome in 9 patients with compression ranging from the occiput to C6.

METHODS

We utilized a posterior approach for lesions rostral to C4 and an anterior approach for lesions at or caudal to C4. Furthermore, we demonstrated the feasibility and efficacy of a minimally invasive posterior cervical approach. Patient profile, operative indications, surgical approach, operative findings, complications, and long-term follow-up were reviewed and discussed.

RESULTS

Average follow-up was 47 months. All procedures provided excellent outcomes by Glasgow Outcome Scale scores. The anterior approach had significantly less blood loss (187.5 mL vs 450 mL, P = .00016) and shorter hospitalization length (2 days vs 4.5 days; P = .0001) compared with the far-lateral approach. There was one complication of cervical instability in the far-lateral approach cohort. As an alternative to the far-lateral surgery, a minimally invasive approach resulted in shorter hospitalization (2 days) and less blood loss (10 mL) while avoiding the complication of cervical instability.

CONCLUSION

We demonstrated the safety, efficacy, and durability of 3 surgical approaches for RVAS. Proper examination, preoperative imaging, and surgical planning were necessary for a satisfactory outcome.

[Injury to the subclavian and vertebral arteries in childhood following blunt force trauma]

Injuries of great vessels, such as the subclavian or vertebral arteries in childhood are rare. More frequent and therefore better described are dissections of the vertebral artery, which frequently occur following low energy trauma. The combination of dissection of the vertebral and subclavian arteries described in this case study led to sensory affections of the left arm. Therapeutic anticoagulation is the therapy of choice to avoid possible ischemic insults. The therapeutic approach of injuries to the subclavian artery remains unclear and is in the focus of discussions.

Subaxial positional vertebral artery occlusion corrected by decompression and fusion

STUDY DESIGN

A rare case of subaxial vertebral artery (VA) positional occlusion is reviewed and treatment methods discussed.

OBJECTIVE

The decision process involved in treating subaxial VA positional occlusion is reviewed.

SUMMARY OF BACKGROUND DATA

Bow Hunter stroke is a symptomatic vertebrobasilar insufficiency caused by stenosis or occlusion of the VA with physiologic head rotation. It most commonly occurs at the junction of C1 and C2 and less commonly as the VA enters the C6 transverse foramen. Rotational stenosis of the VA is quite rare during its passage through the foramen transversarium of C3-C6.

METHODS

A 48-year-old gentleman presented describing syncopal episodes when he turns his head to the left side. Imaging revealed a congenitally narrowed right foramen transversarium and high-grade stenosis of the left VA when the head was turned to the left. A routine anterior cervical discectomy and fusion was performed with the addition of decompression of the left transverse foramen.

RESULTS

Vascular imaging should be performed with the patient's head in both the neutral position and in the symptomatic position. Surgical treatment may be chosen if conservative therapies fail and generally has 1 of 2 goals-decompression of the VA or elimination of rotational movement at the affected level. Decisions between anterior and posterior decompressions may be influenced by the surgeon's comfort level with the approach and if the transverse foramen stenosis is caused mainly by an anterior (osteophytes at the uncinate process) or posterior (facet joint hypertrophy) process. The patient remains symptom-free after treatment.

CONCLUSION

This report demonstrates the condition in the subaxial spine and describes successful treatment by fusion of the affected level combined with decompression of the foramen transversarium-a combination of previously described therapies.

Vertebral artery dissections after chiropractic neck manipulation in Germany over three years

Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck. However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a country-wide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation. Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.

Traumatic vascular injuries and their management

Traumatic vascular injury to the intracranial and extracranial circulation can be sequelae of blunt, penetrating, or iatrogenic insults to the head, face, or neck. Treatment options include conservative medical management, or more invasive surgical or endovascular therapy. The appropriate treatment depends on the risk-benefit ratio of each option considering the natural history of each. Injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, fistulas, and occlusions. Need for treatment is partly determined by the collateral circulation to the brain, and the degree to which the lesion is thrombogenic. Advances in endovascular devices and techniques provide us with less invasive alternatives to surgery intervention or allow the interventionalist to treat lesions not treatable by any other modality.

Traumatic rupture of the basilar artery: report of two cases and review of the literature

Two cases of traumatic rupture of the basilar artery are reported. In the first case, severe basal subarachnoid hemorrhage (SAH) due to a complete transverse tear of the basilar artery was observed in a 53-year-old restrained male driver who was involved in a head-on collision while intoxicated and drowsy. He lost consciousness shortly after the accident and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 50 minutes after the accident. The ethanol concentration in his blood and urine was 0.35 and 0.55 mg/ml, respectively. In the second case, SAH due to a similar tear of the basilar artery was observed in a 47-year-old man who received several fist blows to the face while intoxicated. He suddenly lost consciousness after the final blow and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 6 hours after the event. In these cases, the mechanism of the traumatic rupture of the basilar artery is thought to be overstretching due to hyperextension of the head, and intoxication, drowsiness, or both may have interfered with the decedents' ability to protect themselves; thus, the hyperextension of the head may have been rather forceful.

Vertebral artery dissection: spectrum of imaging findings with emphasis on angiography and correlation with clinical presentation

A study was performed to evaluate the relationship between the imaging features and clinical presentation of vertebral artery (VA) dissection. Twenty-two patients with 24 VA dissections at angiography and clinical evaluation also underwent computed tomography and magnetic resonance imaging. The angiographic patterns of VA dissection were categorized as aneurysmal (n = 10) or steno-occlusive (n = 14). All 10 patients (10 lesions) with the aneurysmal pattern had dissection in the V4 (intradural) segment and presented with headache (n = 5), neurologic deficit (n = 2), dizziness (n = 2), or altered mentality (n = 1). However, the 12 patients (14 lesions) with the steno-occlusive pattern had dissection from the V1 segment to the V4 segment and presented with neurologic deficits caused by infarction of an embolic nature. Overall, the most frequent VA dissection site was the V4 segment. The distribution of the dissection sites and the clinical presentation tended to differ according to the angiographic patterns of aneurysm or stenosis-occlusion.

Vertebral artery dissection causing stroke in sport

Five cases of vertebral arterial dissection occurring in sport are presented. These cases emphasise the diagnostic and management difficulties in this setting. Stroke in sport, although uncommon, is predominantly due to arterial dissection in either the vertebral or carotid arteries. Physicians involved in athlete care need to be aware of this diagnosis.

Recognizing vertebral artery dissection in children: a case report

Vertebral artery dissection is an unusual cause of stroke especially in children. The majority of dissections are thought to be caused by trauma although in many cases the trauma may be trivial. In other cases, certain underlying pathological processes are thought to be risk factors. We report a case of vertebral artery dissection in a 9-year-old child who presented with neurologic deficits suggestive of a posterior circulation stroke. The signs and symptoms of this unusual entity can be subtle and intermittent over a period of days to weeks; thus, making it very difficult to recognize. Therefore, it is important to consider the possibility of vertebral artery dissection in the differential diagnosis of neurologic deficits in children.

Deaths due to brain injury among footballers in Victoria, 1968-1999

OBJECTIVES

To determine the frequency and nature of fatal brain injuries occurring in Australian football.

SETTING

State of Victoria, January to July 1999.

DESIGN

Retrospective case series of football-related deaths identified from the coronial autopsy records of the Victorian Institute of Forensic Medicine (1990-1999) and newspaper reports (1968-1989).

MAIN OUTCOME MEASURES

Coronial autopsy findings and circumstances of injury.

RESULTS

25 deaths associated with Australian football were identified, nine due to brain injury. Coronial findings in the brain-injury deaths were intracranial haemorrhage in eight patients and infarct in the territory of the middle cerebral artery in one. In three of four cases of subarachnoid haemorrhage, vertebral artery trauma was noted. In all but one case, injury occurred as an accidental part of play.

CONCLUSIONS

The most common findings in deaths due to brain injury in Australian football were intracranial haemorrhage, including subarachnoid haemorrhage from vertebral artery injury.

Spontaneous bilateral vertebral artery dissections: case report and literature review

Vertebral artery dissection (VAD) has been increasingly identified as a cause of ischemic stroke in young adults. We report the clinical and radiographic findings in a case of spontaneous bilateral VADs and review the literature on the causes, pathophysiology, diagnostic considerations, and treatment options for VAD. A 29-year-old man was admitted to our hospital after sudden onset of headache and nuchal rigidity that progressed to a posterior lateral medullary syndrome in a 2-week period. The diagnosis of bilateral VADs was based on findings on cranial magnetic resonance imaging and conventional angiography. The patient was given anticoagulant therapy and had no further neurologic deterioration. The differential diagnosis of craniocervical pain in young patients should include arterial dissection of the neck because early diagnosis and treatment may reduce the chances of long-term neurologic sequelae.

Blunt cerebrovascular injuries

On the basis of our experience and the available literature, we submit that aggressive screening for BCI based on injury patterns is warranted. However, several important clinical issues remain unresolved. The precise injury patterns and relative cerebrovascular risks remain to be defined. Furthermore, the optimal diagnostic screening test remains to be identified, with consideration of the relative risk-benefit profile. Finally, we must determine the best methods for the treatment of BCI. Although the definitive study has yet to be completed, the use of heparin was associated with a trend toward improved outcomes in symptomatic patients. In addition, no asymptomatic patient experienced the development of new neurologic deficits during heparin therapy. Therefore we believe that the early institution of heparin therapy is indicated. The role of endovascular stenting, however, remains unclear.