Vertebral artery section for treating arterial compression of the medulla oblongata. Case report

Opalski syndrome, a rare variant of wallenberg syndrome, the first case reported from Pakistan: A case report

Background

Wallenberg syndrome, also known as a lateral medullary syndrome, is a rare neurological condition caused by an infarction in the brainstem's lateral medulla. There are subtypes of Wallenberg syndrome with distinctive and atypical symptoms, such as Opalski syndrome.

Case presentation

A 41-year-old hypertensive male arrived at the emergency department with abrupt onset of right-sided bodily weakness, vertigo, facial numbness, dysphagia, hoarseness of voice, and double vision. The neurological examination indicated right hemiparesis, right facial numbness, crossed sensory deficit, right limb ataxia, right uvulopalatal deviation, and vertical double vision. An MRI showed a lateral medullary infarct leading to the suspicion of the atypical lateral medullary syndrome. The patient was treated with physiotherapy and daily oral medications including aspirin, clopidogrel, atorvastatin, and Cap Risek. On follow-up 14 days later, the patient's condition had significantly improved.

Conclusion

This case study demonstrates the significance of recognizing atypical variants of Wallenberg syndrome, such as Opalski syndrome, in order to provide a correct diagnosis and the most effective treatment. Our patient's condition improved as a result of the therapy measures used, however, people with Opalski syndrome may have a poor prognosis and require continuous monitoring.

Medullary Compression Due to Ectatic Vertebral Artery-Case Report and Review of Literature

Medullary compression syndrome due to anomalous course of blood vessels is a rare disease most commonly seen in the adult population. The offending vessels causing this syndrome are mostly posterior inferior cerebellar artery or the vertebral artery. The symptoms of this syndrome vary from most common hypertension to various other neurologic deficits like hemiplegia, dysesthesia, and dysarthria. Intractable dizziness is a rare symptom of this disease. The definite management plan for this disease is microvascular decompression. We present our case of medullary compression syndrome which manifested as intractable dizziness. We describe our experience in the management of this patient as well as present a review of literature of this rare disease.

Successful microvascular decompression surgery for dolichoectatic vertebral artery compression of medulla oblongata in a patient with hypersomnia disorder

INTRODUCTION

Hypersomnia is a condition in which a person has trouble staying awake during the day. There are several potential causes of it, including sleep apnea and sleep disorders.

CASE PRESENTATION

A 43 year old male was referred to our practice with complaints of hypersomnia, snoring, slurred speech and sleep apnea for more diagnostic and therapeutic interventions. His brain MRI was significant for a vascular loop compression on medulla oblongata. The patient underwent microvascular decompression surgery subsequently and showed improvement in all of his symptoms.

CONCLUSION

One of the rare causes of sleep apnea is medulla oblongata compression by a vascular loop. Vertebrobasilar dolichoectasia may cause this phenomenon probably and should be reviewed in imaging examinations more precisely. Microvascular decompression by using a synthetic Teflon patch may be helpful in management of these patients.

Vertebral artery dolicoectasia with brainstem compression: role of microvascular decompression in relieving pyramidal weakness

Vertebral artery dolicoectasia (VAD) can cause brainstem compression and dysfunction. Reports of pyramidal tract involvement by brainstem compression and the surgical benefits and its long-term results are sparsely reported. We hereby report three cases of medullary compression by VAD causing pyramidal weakness. Two patients with bilateral compression with quadriparesis did not want surgical treatment and were still disabled at 58 months and 50 months of follow-up, respectively. One patient with unilateral medullary compression with hemiparesis underwent microvascular decompression using Teflon sling retraction. This patient was relieved of symptoms and is asymptomatic at 14-month follow-up. This report emphasizes the need of surgical decompression in cases of brainstem compression by VAD with caution about appropriate case selection.

Microvascular decompression of a C-2 segmental-type vertebral artery producing trigeminal hypesthesia

The authors report a case of trigeminal hypesthesia caused by compression of the spinal cord by a C-2 segmental-type vertebral artery (VA) that was successfully treated with microvascular decompression. Aberrant intradural VA loops have been reported as causes of cervical myelopathy, some of which improved with microvascular decompression. A 52-year-old man presented with progressive complaints of headache, dizziness, left facial numbness, and left upper-extremity paresthesia that worsened when turning his head to the right. Magnetic resonance imaging of the cervical spine showed the left VA passing intradurally between the axis and atlas, foregoing the C-1 foramen transversarium, and impinging on the spinal cord. The patient underwent left C-1 and C-2 hemilaminectomies followed by microvascular decompression of an aberrant VA loop compressing the spinal cord. The patient subsequently reported complete resolution of symptoms.

Acute brainstem compression by intratumoral hemorrhages in an intracranial hypoglossal schwannoma

A 77-year-old female in the hospital was found tachycardic and hypothermic by a nurse, and the patient's respiration subsequently ceased. Forensic autopsy revealed an intracranial cystic tumor that would have compressed the brainstem. On microscopic examination, the tumor was diagnosed as an Antoni A schwannoma growth, and recent multiple intratumoral hemorrhages in the intracranial schwannoma were observed, suggesting the sudden enlargement of the intracranial schwannoma due to intratumoral hemorrhaging. Accordingly, we diagnosed the cause of death as brainstem compression induced by the intratumoral hemorrhaging in the intracranial schwannoma. Meanwhile, a rhinopharyngeal tumor was also detected by the autopsy, which was compatible with an antemortem diagnosis of a dumbbell-shaped hypoglossal schwannoma.

Opalski syndrome caused by vertebral artery compression of the lateral surface of the medulla oblongata

A 55-year-old man presented with vertigo, nystagmus, and gait ataxia followed by left hemiparesis (Opalski syndrome). T2-weighted magnetic resonance imaging revealed vascular compression of the left lateral side of the medulla oblongata by the left vertebral artery. On diffusion tensor imaging, the level of fractional anisotropy (FA) in the left corticospinal fibers caudal to the pyramidal decussation was lower than that observed in the right corticospinal fibers. Opalski syndrome caused by vascular compression is very rare. This is the first reported case of Opalski syndrome that was imaged on FA.

[A case of medulla oblongata compression by tortuous vertebral arteries presenting with spastic quadriplegia]

We report a 58-year-old man showing spastic paraparesis due to medulla oblongata compression by tortuous vertebral arteries. He noticed weakness of both legs and gait disturbance at the age of 58 years and his symptoms progressively worsened during the following several months. General physical findings were normal. Blood pressure was normal and there were no signs of arteriosclerosis. Neurological examination on admission revealed lower-limb-dominant spasticity in all four extremities, lower-limb weakness, hyperreflexia in all extremities with positive Wartenberg's, Babinski's and Chaddock's signs, mild hypesthesia and hypopallesthesia in both lower limbs, and spastic gait. Cranial nerves were all normal. Serum was negative for antibodies against human T-cell lymphotropic virus-1 antibody. Nerve conduction and needle electromyographic studies of all four limbs revealed normal findings. Cervical, thoracic and lumbo-sacral magnetic resonance imaging (MRI) findings were all normal. Brain MRI and magnetic resonance angiography demonstrated bilateral tortuous vertebral arteries compressing the medulla oblongata. Neurovascular decompression of the right vertebral artery was performed because compression of the right side was more severe than that of the left side. Post-operative MRI revealed outward translocation of the right vertebral artery and relieved compression of the medulla oblongata on the right side. The patient's symptoms and neurological findings improved gradually after the operation. Bilateral pyramidal tract signs without cranial nerve dysfunction due to compression of the medulla oblongata by tortuous vertebral arteries are extremely rare and clinically indistinguishable from hereditary spastic paraplegia (HSP). Although we did not perform a genetic test for HSP, we consider that the spastic paraparesis and mild lower-limb hypesthesia were caused by compression of the medulla oblongata by bilateral tortuous vertebral arteries based on the post-operative improvement in symptoms. Given the favorable effects of surgery, tortuous vertebral arteries should be considered in the differential diagnosis of patients presenting with progressive spastic paraparesis.

The long-term follow-up of surgical treatment for cervical myelopathy with severe nape and upper arm pain caused by the anomalous vertebral artery: case report

STUDY DESIGN

A case of cervical myelopathy with a severe nape and upper arm pain caused by anomalous bilateral vertebral arteries is reported.

OBJECTIVE

To report over six and a half years results of a microsurgical decompression for high cervical myelopathy with a severe pain of nape and upper arm resulting from spinal cord compression by the anomalous vertebral arteries.

SUMMARY OF BACKGROUND DATA

Although symptomatic cases of anomalies of vertebral artery (VA), such as fenestration or elongation, leading to severe cervical pain, cervical myelopathy, or accessory nerve palsy have been reported, no long-term results of microsurgical decompression for those cases have been reported.

METHODS

The clinical features of the case and over 6(1/2) years results of microsurgical decompression by retracting the arteries with silicon tapes and a dural patch are reported. An etiology and the treatment of the cases are discussed with a review of the previous documented cases.

RESULTS

The cord compression was relieved surgically, and the patient's symptoms have improved after surgery throughout the follow-up period.

CONCLUSION

Anomalous vertebral arteries should be included in the differential diagnosis of the upper cervical lesion of unknown origin. The microsurgical decompression with presented technique has relieved the symptoms for over 6(1/2) years.

Treatment of vertebral artery dissecting aneurysms presenting with progressive myelopathy

Two patients with vertebral artery dissecting aneurysm are presented in which the posterior inferior cerebellar artery (PICA) arose from the wall of the aneurysm. The patients presented with progressive myelopathy due to mass effect on the medulla. One patient was treated with proximal occlusion of the vertebral artery using Guglielmi detachable coils (GDCs). The other patient underwent complete excision of the aneurysm, with reimplantation of the PICA into the vertebral artery proximal to the dissecting aneurysm. We obtained good results with improvement of myelopathy in both patients, but the patient who underwent bypass surgery suffered longstanding palsy of the lower cranial nerves. This report emphasizes that complete aneurysm clipping or excision for such patients is the gold standard of treatment, but preservation of PICA flow may require technically sophisticated surgical techniques. However, even if the aneurysm is not completely eliminated, the myelopathy can be dramatically improved with conservative endovascular treatment with proximal occlusion. Therefore, the choices for treatment in such lesions varies with the angiographic findings, degrees of mass effect on the brainstem, and the patient's physical condition.

Landmarks for vertebral artery repositioning in bulbar compression syndrome: anatomic and microsurgical nuances

OBJECTIVE

The purpose of this study was to better elucidate the anatomic relationship between the vertebral artery (VA) along with its perforating vessels and the brainstem to develop anatomic guidelines that would be helpful when decompressing medulla oblongata compressed by the VA.

METHODS

Microanatomy dissection was performed in six formalin-fixed cadaveric heads. The VA, posteroinferior cerebellar artery (PICA), anteroinferior cerebellar artery (AICA), and lower brainstem perforators were examined under magnification using a surgical microscope. The outer diameters of the VA, PICA, and AICA were measured. The distance between the VA, lying within the lateral cerebellomedullary cistern, and the medulla oblongata was quantified. The lower brainstem perforating vessels were examined in relation to their course, outer diameter, and length.

RESULTS

In four of six brains, the left VA was dominant, presenting an outer diameter at least 0.8 mm larger than the contralateral VA. The average distance between the VA and the medulla oblongata was 3 mm. The perforating branches presented a mean outer diameter of 0.7 mm. In particular, perforators arising from the VA and PICA (Groups 1 and 2) presented an average outer diameter of 0.2 mm and an average length of 7 mm. Perforating vessels arising from the AICA and vertebrobasilar junction (Groups 3 and 4) presented an average outer diameter of 0.4 mm and an average length of 12 mm.

CONCLUSION

This work provides new information that may be useful to minimize the risk of injury of perforators when operating on medulla oblongata compression by the VA.

Thrombosed vertebral artery aneurysm presenting with hemorrhage and bulbar compression: report of two cases

Bulbar compression by vertebral artery (VA) aneurysm is extremely rare and only reported in a few cases. We report two cases with thrombosed VA aneurysm compressing medulla oblongata; one presented with bulbar apoplexy hemorrhage and the other with subarachnoid hemorrhage (SAH). A 61-year-old male (case 1) presented with consciousness disturbances, left hemiplegia, and subsequent respiratory arrest. He was subjected to controlled ventilation, and computed tomography (CT) scan showed bulbar hemorrhage. Magnetic resonance imaging (MRI) and digital subtraction angiogram (DSA) revealed fusiform right VA aneurysm with partial thrombosis and bulbar compression. Intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) relieved his clinical symptom including respiratory disturbance. Three months after the onset, he remained moderately disabled. A 76-year-old male (case 2) presented with severe headache and subsequent respiratory disturbance. CT scan on admission showed subarachnoid hemorrhage with acute hydrocephalus. Ventricular drainage rapidly improved consciousness while respiratory disturbance persisted over several days. MRI and DSA suggested spontaneous thrombosis of the right VA dissection with bulbar compression. He showed gradual recovery of his respiration over a week. After ventriculo-peritoneal shunting, he was transferred with moderate disability. These results suggest that the elimination of the pulsatile effect of VA aneurysm adjacent to medulla oblongata can improve symptoms caused by aneurysm-related compression. Early diagnosis and appropriate treatment such as intra-aneurysmal embolization for ameliorating the blood flow inside the aneurysm can relieve mass effect and clinical symptoms.

Bulbar Compression by an Ectatic Vertebral Artery: A Novel Neurovascular Construct Relieved by Microsurgical Decompression

OBJECTIVE:

Brainstem compression caused by vascular abnormalities has rarely been reported in the literature. We describe five cases of large ectatic vertebral artery causing compression and distortion of the medulla oblongata with pyramidal tract signs and low cranial nerve dysfunction. Microvascular decompression by retracting the vertebral artery and anchoring it to the dura has been the treatment of choice.

METHODS:

Five patients, four male and one female, presented with progressive myelopathic features and lower cranial nerve dysfunction, especially dysphonia and dysphagia. Four patients were affected by systemic arterial hypertension. Magnetic resonance imaging showed impingement of the right vertebral artery in three patients and the left vertebral artery in two patients, on the right and left lateral medulla, respectively. In two patients, hypoplasia of the contralateral vertebral artery was documented.

RESULTS:

All patients underwent neurovascular decompression of the medulla oblongata. The ectatic and tortuous vertebral artery was detached from the medulla, shifted away, and repositioned by anchoring to the nearby dura mater using a Gore-Tex vascular slip. Postoperatively, all patients but one had improvement of their previous neurological symptoms.

CONCLUSION:

Brainstem dysfunction caused by a tortuous ectatic vertebral artery might be less uncommon than expected. It should be considered a new distinct clinical entity, the real incidence of which needs to be carefully evaluated by an appropriate diagnostic protocol, which includes primarily magnetic resonance imaging with specific three-dimensional sequences. Awareness of this condition is necessary to ensure the appropriate treatment. Surgical microvascular decompression seems very effective.

Brain-stem compression in vertebrobasilar dolichoectasia. A multimodal electrophysiological study

OBJECTIVE

To evaluate the effects of mechanical compression of the brain-stem in patients with vertebrobasilar dolichoectasia (VBD).

METHODS

In the framework of a prospective, observational study that collected clinical and laboratory data in patients with VBD, we studied 20 patients with compression of the brain-stem due to ectatic, tortuous basilar or vertebral arteries. Patients with cerebral lesions other than small lacunae in the white matter of the cerebral hemispheres were excluded from the study. Patients underwent vestibular and auditory function testing, including brain-stem auditory evoked potentials (BAEPs), blink reflex (BR), somatosensory evoked potentials (SEPs), and motor evoked potentials (MEPs).

RESULTS

Almost all of the patients complained of auditory or vestibular symptoms and none had symptoms or signs of impairment of long tracts or the facial and trigeminal nerves. The most consistent findings were BR abnormalities with prolongation of ipsilateral R1 latency in cases of compression of the pons (10/16) and prolongation of the R2 and R2c latencies with compression of the medulla oblongata (5/15). Subclinical impairment of corticospinal pathways was found in 13 out of 25 instances of compression, and this was more frequent with compression of the pons. Abnormal BAEPs or SEPs were less frequently encountered, and only in cases with compression of the pons.

CONCLUSIONS

Neurovascular compression of the brain-stem, even with severe distortion, is seldom associated with overt clinical signs, whereas subclinical dysfunctions are relatively frequent. The central pathways of the BR and the corticospinal pathways are more susceptible to compression than acoustic and sensory pathways. BR, MEP and BAEP data provide a functional evaluation of the brain-stem and some cranial nerves, which is lacking in imaging studies. Functional investigations may be useful in the long-term management of these patients, since VBD may be progressive and surgical correction may be required at some stage.

Cervical myelopathy due to compression by bilateral vertebral arteries--case report

A 69-year-old man presented with progressive cervical myelopathy due to vascular compression of the upper cervical spinal cord. Vertebral angiography and magnetic resonance imaging revealed that the elongated bilateral vertebral arteries (VAs) had compressed the spinal cord at the C-2 level. The spinal cord was surgically decompressed laterally by retracting the VAs with Gore-Tex tape and anchoring them to the dura. The patient's symptoms improved postoperatively. Decompression and anchoring of the causative vessels is recommended due to the large size of the VAs.

Anchoring method for hemifacial spasm associated with vertebral artery: technical note

OBJECTIVE

We describe an easy and useful method for treating hemifacial spasm related to the vertebral artery.

METHODS

The technique entails the manufacture of a dural belt harvested from the cerebellar convexity dura and a dural bridge made at the petrous dura combined with the use of an aneurysm clip. The dural belt holds the vertebral artery and is anchored to the dural bridge by fixation with an aneurysm clip after the vertebral artery is transposed to an appropriate position.

RESULTS

The technique proved to be safe and effective in a series of six patients with hemifacial spasm who were followed up for a period of 2 months to more than 10 years after surgery. All patients were affected on the left side. Multiple offending arteries were present in three cases. Hemifacial spasm completely disappeared in all patients.

CONCLUSION

This method represents a feasible option for the treatment of hemifacial spasm caused by a tortuous, elongated, or enlarged vertebral artery.

Vascular compression of the medulla oblongata by the vertebral artery: report of two cases

OBJECTIVE AND IMPORTANCE

Compression of the medulla oblongata by a tortuous vertebral artery is rare. We report two patients with this lesion who were treated with vascular decompression of the vertebral artery.

CLINICAL PRESENTATION

A 36-year-old man developed right hemiparesis with lower cranial nerve deficits, and a 47-year-old man developed left lower cranial nerve deficits and left cerebellar dysfunction. In both patients, magnetic resonance imaging revealed a tortuous vertebral artery compressing the medulla oblongata.

INTERVENTION

In both patients, the compressed medulla oblongata was treated by detaching the vertebral artery from the medulla oblongata, shifting it, and anchoring it to the nearby dura mater. Postoperatively, both patients are asymptomatic and have returned to their previous jobs.

CONCLUSION

Although compression of the medulla oblongata by a tortuous vertebral artery is rare, it can cause brainstem dysfunction. Magnetic resonance imaging clearly revealed the vascular compression in these patients. Surgical treatment was effective. The symptoms related to a tortuous vertebral artery and some techniques for surgical treatment are discussed. Awareness of this rare lesion is necessary to ensure appropriate treatment.

Repositioning of the vertebral artery as treatment for neurovascular compression syndromes. Technical note

Neurovascular compression syndromes are usually treated by interposing Teflon felt or padding or some other implant between the offending vessel and the nerves. However, this cannot be done in some cases in which ectatic vertebrobasilar arteries are involved. In these instances, alternative techniques must be used. The authors report the use of a sling made of Prolene to reposition the vertebral artery in two patients with neurovascular compression disorder. The clinical results were gratifying, with complete resolution of the patients' symptoms. Compression by large vessels is an uncommon but important source of neurovascular compression in patients with trigeminal neuralgia, hemifacial spasm, disabling positional vertigo, and, possibly, hypertension. The technique described may be useful to surgeons treating these problems.

Cervical myelopathy caused by the anomalous vertebral artery. A case report

STUDY DESIGN

A case of cervical myelopathy caused by an anomalous vertebral artery is reported.

OBJECTIVES

To report a case of high cervical myelopathy resulting from spinal cord compression by an anomalous vertebral artery. Authors believe that this is the first reported case in which the nutrient artery to the abnormal artery originated from the posterior inferior cerebellar artery.

SUMMARY OF BACKGROUND DATA

Although fenestration of the vertebral artery is net an unusual anomaly to the best of the authors knowledge, three cases of high cervical myelopathy resulting from the anomaly were reported. There is no reported case in which an abnormal artery originated from the posterior inferior cerebellar artery.

METHODS

The clinical features of the case are reported and discussed with a review of the previously documented cases.

RESULTS

The cord compression war relieved surgically, and the patient's symptoms improved postoperatively.

CONCLUSIONS

A fenestrated vertebral artery should be included in the differential diagnosis of the upper cervical or the craniovertebral junctional lesions of unknown origin. Magnetic resonance imaging is useful for the diagnosis. In the present case, there was an anomalous branch entered as a nutrient artery from the posterior inferior cerebellar artery. Careful management for similar abnormal arteries includes surgery.