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Wang X, Tong X. Vascular reconstruction related to the extracranial vertebral artery: the presentation of the concept and the basis for the establishment of the bypass system. Front Neurol 2023; 14:1202257. [PMID: 37388550 PMCID: PMC10301721 DOI: 10.3389/fneur.2023.1202257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/02/2023] [Indexed: 07/01/2023] Open
Abstract
The intracranial vertebrobasilar artery system has a unique hemodynamic pattern (vessel trunk converged bilateral flow with three groups of perforators directly arising from it), is embedded within intense osseous constraints, and is located far from conventional donor vessels. Two major traditional modalities of posterior circulation revascularization encompass the superficial temporal artery to the superior cerebellar artery and the occipital artery to the posteroinferior cerebellar artery anastomosis, which are extracranial-intracranial low-flow bypass with donor arteries belonging to the anterior circulation and mainly supply focal perforators and distal vascular territories. As our understanding of flow hemodynamics has improved, the extracranial vertebral artery-related bypass has further evolved to improve the cerebral revascularization system. In this article, we propose the concept of "vascular reconstruction related to the extracranial vertebral artery" and review the design philosophy of the available innovative modalities in the respective segments. V1 transposition overcomes the issue of high rates of in-stent restenosis and provides a durable complementary alternative to endovascular treatment. V2 bypass serves as an extracranial communication pathway between the anterior and posterior circulation, providing the advantages of high-flow, short interposition grafts, orthograde flow in the vertebrobasilar system, and avoiding complex skull base manipulation. V3 bypass is characterized by profound and simultaneous vascular reconstruction of the posterior circulation, which is achieved by intracranial-intracranial or multiple bypasses in conjunction with skull base techniques. These posterior circulation vessels not only play a pivotal role in the bypass modalities designed for vertebrobasilar lesions but can also be implemented to revascularize the anterior circulation, thereby becoming a systematic methodology.
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Affiliation(s)
- Xuan Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
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2
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Seung WB. A Modified Surgical Technique for Transposition of the Vertebral Artery to the Common Carotid Artery. Case Rep Neurol 2018; 10:292-296. [PMID: 30483104 PMCID: PMC6244107 DOI: 10.1159/000493725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 11/26/2022] Open
Abstract
A proximal occluded vertebral artery (VA) with reconstitution by muscular collateral vessels is a relatively common finding. However, due to inadequate intracranial anastomosis and hypoplasia or stenosis of the opposite VA, a number of patients develop symptoms of brain ischemia. In the current case, a 63-year-old man presented with repeat neurological symptoms such as dizziness, nausea, vomiting, dysarthria, left hemiparesis, and right hemianopsia. Magnetic resonance imaging revealed multiple posterior infarctions. Angiography revealed the VA to be occluded and reconstituted by collateral vessels. Considering the above results, we performed vertebral carotid artery transposition. However, several technical difficulties were encountered due to space limitations in the operative field and the limited length of the vessels to be anastomosed. To overcome such situations, we introduced a modified posterior wall end-to-side anastomosis technique.
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Affiliation(s)
- Won-Bae Seung
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Republic of Korea
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3
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Wang X, Tong X, Shi M, Shang Y, Wang H. Occipital Artery to Extradural Vertebral Artery Bypass for Posterior Circulation Ischemia. Oper Neurosurg (Hagerstown) 2018; 16:527-538. [DOI: 10.1093/ons/opy143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 05/05/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Posterior circulation ischemic strokes can have devastating consequences, despite medical therapies. Extracranial–intracranial bypass for the augmentation of flow is a treatment option for selected patients with hemodynamic compromise and recurrent ischemia. However, posterior circulation bypass carries a higher risk and lower patency rate than bypass with anterior circulation.
OBJECTIVE
To present the occipital artery to the extradural vertebral artery (OA-eVA) bypass for posterior circulation ischemia.
METHODS
We retrospectively reviewed our experience of the OA-eVA bypass surgery in the treatment of bilateral vertebral steno-occlusive disease.
RESULTS
Seventeen patients were identified. Thirteen patients had bilateral vertebral artery (VA) occlusion (type I), while 4 patients had VA occlusion with contralateral VA severe stenosis (type II). All patients had cerebellar or pons infarction, for which the postoperative bypass patency rate was 100%, with carotid angiogram demonstrating excellent filling of the rostral basilar system or the posterior inferior cerebellar artery territory. The long-term follow-up outcome was favorable (modified Rankin score of 0-2) in 82% of patients (7 patients had complete resolution and 7 had improvement of symptoms) and unfavorable in 18%. One type II case without previous endovascular therapy developed recurrent ischemic onset associated with bypass occlusion.
CONCLUSION
OA-eVA bypass is a minimally invasive and effective alternative to posterior circulation ischemia. It provides sufficient blood flow augmentation to the vertebrobasilar territory. The advantages of this novel therapeutic strategy include avoiding performing craniotomy and deep bypass and achieving shorter operative times compared to conventional bypass surgery.
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Affiliation(s)
- Xuan Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Hu Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
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4
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Ren X, Li M, Zhao X, Liu Z, Ren S, Zhang Y, Zhang S, Canavero S. First cephalosomatic anastomosis in a human model. Surg Neurol Int 2017; 8:276. [PMID: 29279793 PMCID: PMC5705925 DOI: 10.4103/sni.sni_415_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background: Cephalosomatic anastomosis (CSA) has never been attempted before in man as the transected spinal cords of the body donor and body recipient could not be “fused” back together. Recent advances made this possible. Here, we report on the surgical steps necessary to reconnect a head to a body at the cervical level. Methods: Full rehearsal of a CSA on two recently deceased human cadavers was performed at Harbin Medical University, Harbin, China. Results: The surgery took 18 hours to complete within the time frame planned for this surgery. Several advances resulted from this rehearsal, including optimization of the surgical steps, sparing of the main nerves (phrenics, recurrent laryngeal nerves), and assessment of vertebral stabilization. Conclusion: Several specialties are involved in a full-scale CSA, including neck surgery, vascular surgery, orthopedic surgery, plastic surgery, gastrointestinal surgery, and neurosurgery, as well as the operating staff. This rehearsal confirmed the surgical feasibility of a human CSA and further validated the surgical plan. Education and coordination of all the operating teams and coordination of the operative staff was achieved in preparation for the live human CSA.
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Affiliation(s)
- Xiaoping Ren
- Hand and Microsurgical Center, 2 Affiliated Hospital, Harbin Medical University, Harbin, China.,State-Province Key Laboratories of Biomedicine-Pharmaceutics, Harbin Medical University, Harbin, China.,Heilongjiang Medical Science Institute, Harbin Medical University, Harbin, China.,Department of Molecular Pharmacology and Therapeutics, Stritch School of Medicine, Loyola University, Chicago, Illinois, USA
| | - Ming Li
- Hand and Microsurgical Center, 2 Affiliated Hospital, Harbin Medical University, Harbin, China.,State-Province Key Laboratories of Biomedicine-Pharmaceutics, Harbin Medical University, Harbin, China.,Heilongjiang Medical Science Institute, Harbin Medical University, Harbin, China
| | - Xin Zhao
- Hand and Microsurgical Center, 2 Affiliated Hospital, Harbin Medical University, Harbin, China.,State-Province Key Laboratories of Biomedicine-Pharmaceutics, Harbin Medical University, Harbin, China.,Heilongjiang Medical Science Institute, Harbin Medical University, Harbin, China
| | - Zehan Liu
- Hand and Microsurgical Center, 2 Affiliated Hospital, Harbin Medical University, Harbin, China.,State-Province Key Laboratories of Biomedicine-Pharmaceutics, Harbin Medical University, Harbin, China.,Heilongjiang Medical Science Institute, Harbin Medical University, Harbin, China
| | - Shuai Ren
- Hand and Microsurgical Center, 2 Affiliated Hospital, Harbin Medical University, Harbin, China.,State-Province Key Laboratories of Biomedicine-Pharmaceutics, Harbin Medical University, Harbin, China.,Heilongjiang Medical Science Institute, Harbin Medical University, Harbin, China
| | - Yafang Zhang
- Department of Anatomy, Harbin Medical University, Harbin, China
| | - Shide Zhang
- Department of Radiology, 2 Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Sergio Canavero
- Turin Advanced Neuromodulation Group, Turin, Italy, Harbin Medical University, Harbin, China
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Kakino S, Ogasawara K, Kubo Y, Kashimura H, Konno H, Sugawara A, Kobayashi M, Sasaki M, Ogawa A. Clinical and angiographic long-term outcomes of vertebral artery–subclavian artery transposition to treat symptomatic stenosis of vertebral artery origin. J Neurosurg 2009; 110:943-7. [DOI: 10.3171/2008.10.jns08687] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although angioplasty and stent placement for vertebral artery (VA)–origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA–subclavian artery (SA) transposition.
Methods
Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46–76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin.
Results
Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced to ≤ 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as > 50% luminal narrowing, in all of them.
Conclusions
The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.
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Affiliation(s)
| | | | | | | | | | | | | | - Makoto Sasaki
- 2Radiology, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
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6
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Streefkerk HJN, Van der Zwan A, Verdaasdonk RM, Beck HJM, Tulleken CAF. Cerebral revascularization. Adv Tech Stand Neurosurg 2003; 28:145-225. [PMID: 12627810 DOI: 10.1007/978-3-7091-0641-9_3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
During the last 10 years, there has been a revival of interest in cerebral revascularization procedures. Not only have significant progressions in surgical techniques been published, the use of more advanced diagnostic methods has led to a widening of the indications for cerebral bypass surgery. The purpose of this review is to outline the current techniques for extracranial-to-intracranial (EC/IC) and intracranial-to-intracranial (IC/IC) bypass surgery, as well as to identify the current indications for revascularization procedures based on the available literature. The excimer laser-assisted non-occlusive anastomosis (ELANA) technique is described in more detail because we think that this technique almost completely eliminates the risk of cerebral ischemia due to the temporary vessel occlusion which is currently used in conventional anastomosis techniques.
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Affiliation(s)
- H J N Streefkerk
- Department of Neurosurgery, Brain Division, University Medical Center-Utrecht, The Netherlands
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7
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Affiliation(s)
- B George
- Department of Neurosurgery, Hôpital Lariboisière, Paris, France
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8
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Mabuchi S, Kamiyama H, Abe H. Distal ligation and revascularization from external carotid to vertebral artery with radial artery graft for treatment of extracranial vertebral artery dissection. Report of a case. Acta Neurochir (Wien) 1993; 125:192-5. [PMID: 8122550 DOI: 10.1007/bf01401852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We present a case of dissection of the extracranial vertebral artery with prominent occipital pain and elements of the lateral medullary syndrome. Arteriography showed a string and pearl sign. Magnetic resonance imaging allowed visualization of an intramural thrombus associated with a narrow vascular lumen. The distal portion of the diseased artery was ligated and vascular reconstruction using an interposed radial artery graft was performed. Pathological studies confirmed the diagnosis. The diagnostic roles of angiography and magnetic resonance imaging, and therapeutic strategies are discussed.
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Affiliation(s)
- S Mabuchi
- Department of Neurosurgery, Kushiro Rosai Hospital, Hokkaido, Japan
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9
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Distal ligation and revascularization from external carotid to vertebral artery with radial artery graft for treatment of extracranial vertebral artery dissection. Report of a case. Acta Neurochir (Wien) 1993. [PMID: 8122550 DOI: 10.1007/bf01401852.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present a case of dissection of the extracranial vertebral artery with prominent occipital pain and elements of the lateral medullary syndrome. Arteriography showed a string and pearl sign. Magnetic resonance imaging allowed visualization of an intramural thrombus associated with a narrow vascular lumen. The distal portion of the diseased artery was ligated and vascular reconstruction using an interposed radial artery graft was performed. Pathological studies confirmed the diagnosis. The diagnostic roles of angiography and magnetic resonance imaging, and therapeutic strategies are discussed.
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10
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Miyamoto S, Kikuchi H, Nagata I, Akiyama Y, Itoh K, Yamagiwa O, Asahi S. Saphenous vein graft to the distal vertebral artery between C-1 and C-2 using a lateral-anterior approach. Technical note. J Neurosurg 1992; 77:812-5. [PMID: 1403130 DOI: 10.3171/jns.1992.77.5.0812] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The authors present a modified surgical procedure for extracranial vertebral artery reconstruction. The use of the proposed technique results in access to the V3 segment of the vertebral artery between the C-1 and C-2 vertebrae through the retrojugular space without requiring bone rongeuring. A saphenous vein bypass graft was placed between the common carotid artery and the V3 segment of the vertebral artery in three patients with bilateral occlusive lesions of the proximal vertebral arteries.
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Affiliation(s)
- S Miyamoto
- Department of Neurosurgery, Kyoto University Medical School, Japan
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11
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Comerota AJ, Maurer AH. Surgical correction and SPECT imaging of vertebrobasilar insufficiency due to unilateral vertebral artery stenosis. Stroke 1992; 23:602-6. [PMID: 1561695 DOI: 10.1161/01.str.23.4.602] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Incapacitating vertebrobasilar insufficiency is generally associated with bilateral vertebral artery disease, whereas unilateral vertebral artery stenosis usually is clinically silent. Regional brain perfusion has not been part of the routine evaluation of patients with vertebrobasilar insufficiency. This report describes two patients who had isolated unilateral vertebral artery stenosis operatively corrected to eliminate their incapacitating vertebrobasilar insufficiency. Hindbrain hypoperfusion was identified preoperatively and evaluated postoperatively, then correlated with patient presentation and response to revascularization. CASE DESCRIPTION Two patients with incapacitating vertebrobasilar insufficiency presented with isolated unilateral vertebral artery stenosis with patent, nonstenotic internal carotid arteries. Hindbrain hypoperfusion was demonstrated by iodine-123-iodoamphetamine single-photon emission computed tomography preoperatively and demonstrated significant improvement following vertebral-carotid reimplantation. The patients' symptoms resolved following revascularization. CONCLUSIONS Although unusual, unilateral vertebral artery stenosis can cause incapacitating vertebrobasilar insufficiency. These cases demonstrate the value of imaging with single-photon emission computed tomography to evaluate regional brain hypoperfusion and to evaluate objectively the results of therapy.
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Affiliation(s)
- A J Comerota
- Department of Surgery, Temple University Hospital, Philadelphia, Pa 19140
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12
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Ogawa A, Yoshimoto T, Sakurai Y. Treatment of proximal vertebral artery stenosis. Vertebral to subclavian transposition. Acta Neurochir (Wien) 1991; 112:13-8. [PMID: 1763678 DOI: 10.1007/bf01402448] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
For vascular reconstruction in cases of atherosclerotic stenosis at the origin of the vertebral artery, we use vertebral to subclavian artery transposition. We discuss the advantages and effectiveness of such treatment based on a study of 32 cases. We have experienced neither surgical mortality nor morbidity and the outcome at the time of discharge has been favourable. Follow-up revealed no deaths, however, three cases exhibited symptoms of cerebral ischaemia. One had a supratentorial completed stroke, and the other two hat TIA or RIND, but without any notable lesion in the angiograms. There were no cases of cerebral infarction of the posterior fossa. We believe that this method should be the first choice for treatment of cases without lesions of the subclavian artery for the following reasons: serious operative complications have not been encountered, surgical invasion is minimal, temporary occlusion of the common carotid artery is unnecessary, the operation can be done by occluding only the vertebral artery, and unlike various bypass operations, anastomosis is required at only one location and is consequently technically uncomplicated. Following anastomosis the cerebral blood pathway is physiological.
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Affiliation(s)
- A Ogawa
- Division of Neurosurgery, Tohoku University, School of Medicine, Sendai, Japan
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13
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Spetzler RF, Hadley MN, Martin NA, Hopkins LN, Carter LP, Budny J. Vertebrobasilar insufficiency. Part 1: Microsurgical treatment of extracranial vertebrobasilar disease. J Neurosurg 1987; 66:648-61. [PMID: 3553453 DOI: 10.3171/jns.1987.66.5.0648] [Citation(s) in RCA: 130] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Extracranial vertebrobasilar artery thrombo-occlusive disease may cause repetitive transient ischemic episodes and, less frequently, brain-stem or cerebellar infarction. This report describes 40 patients who experienced repetitive vertebrobasilar ischemic symptoms despite maximal medical therapy. The natural history, pathogenesis, and treatment options for each causative lesion are reviewed. The operative approaches to symptomatic disease of the proximal vertebral arteries, arterial compression by cervical osteophytes, traumatic lesions of the vertebral arteries, and thrombo-occlusive pathology of the distal extracranial vertebral arteries are outlined. Specific anesthetic and surgical techniques that have proved successful while achieving zero operative mortality and low perioperative morbidity rates are reported.
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Hadley MN, Spetzler RF, Masferrer R, Martin NA, Carter LP. Occipital artery to extradural vertebral artery bypass procedure. Case report. J Neurosurg 1985; 63:622-5. [PMID: 4032027 DOI: 10.3171/jns.1985.63.4.0622] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A 17-year-old boy suffered blunt trauma to the posterior cervical spine and later developed vertebrobasilar transient ischemic attacks refractory to medical management. At angiography, a pseudoaneurysm of the distal left vertebral artery was found. By means of a posterior midline approach, an extradural occipital artery to vertebral artery anastomosis was performed and the affected vertebral artery was clipped distal to the pseudoaneurysm. The indications for this procedure, the operative approach, and the clinical outcome are described.
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