Surgical anatomy and quantitation of the branches of the V2 and V3 segments of the vertebral artery

Object The vertebral artery (VA) and its branches may be encountered during various neurosurgical procedures such as far lateral suboccipital approaches to the skull base and spinal operations. Therefore, a working knowledge of the distribution and significance of such VA branches may be advantageous to the surgeon. To date, quantitation of these branches is lacking in the literature. Methods The authors evaluated the branches of 20 VAs from 10 adult cadavers and assessed the distribution and surgical significance of the branches from the V2 and V3 segments. Results In terms of target tissues, the VA branches encountered at the C1–2 level were most likely to be muscular, branches at C2–3 osseous, and those at C3–6 radicular. No radicular or medullary branches were identified arising from any V3 segment of the VA or C1–2 level of the V2 segment. The greatest concentration of branches per level was found arising from the V2 segment at C2–3. Posterior branches of the VA tended to be radicular or muscular, whereas anterior branches tended to be radicular or osseous. Lateral branches were most commonly radicular and medial branches tended to be osseous or muscular in nature. The largest branches of the VA originated from its V3 segment or the C2–3 part of its V2 segment. Rarely, branches to the extracranial glossopharyngeal and spinal accessory nerves were identified originating from the V3 and V2 segments of the VA, respectively. Conclusions Although seemingly diverse in their distribution, the branches of the V2 and V3 segments of the VA may follow a certain consistent arrangement. The potential for injury to neural branches of the VA is minimal at its V3 segment and the C1–2 portion of its V2 segment. Such knowledge may be of use to the neurosurgeon who operates in the neck and at the craniocervical junction.

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Management of the Vertebral Artery at the Craniocervical Junction

Otolaryngology ◽

10.1016/j.otohns.2005.01.015 ◽

2005 ◽

Vol 133 (1) ◽

pp. 84-88 ◽

Cited By ~ 6

Author(s):

YasLar Çokkeser ◽

Maged B. Naguib ◽

Ahmet Kizilay

Keyword(s):

Vertebral Artery ◽

Skull Base ◽

Cervical Vertebra ◽

Craniocervical Junction ◽

Lateral Approach ◽

Surgical Anatomy ◽

Transverse Foramen ◽

Close Vicinity ◽

Vertebrobasilar Junction

OBJECTIVES: To study the surgical anatomy of the vertebral artery at the craniocervical junction and its related structures defining reliable landmarks for its safe exposure. DESIGN: Ten sides of 5 fresh cadavers were dissected using the lateral approach to the craniocervical junction. RESULTS: Experience gained in studying the anatomic details of the vertebral artery at the craniocervical junction in cadavers from its exit at the transverse foramen of the second cervical vertebra to the vertebrobasilar junction provided the initial background for us to use the lateral approaches to the skull base to safely manage 4 cases with pathology reaching the close vicinity of vertebral artery at the craniocervical junction. CONCLUSION: Thorough knowledge of the anatomy of the vertebral artery is mandatory before attempting surgery at the craniocervical junction. There are reliable landmarks that, when followed, could facilitate safe exposure and identification of the artery.

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Histology of the vertebral artery–dural junction: relevance to posterolateral approaches to the skull base

Journal of Neurosurgery ◽

10.3171/2019.9.jns191394 ◽

2019 ◽

pp. 1-6

Author(s):

Robert C. Rennert ◽

Martin P. Powers ◽

Jeffrey A. Steinberg ◽

Takanori Fukushima ◽

John D. Day ◽

...

Keyword(s):

Connective Tissue ◽

Vertebral Artery ◽

Skull Base ◽

Histological Analysis ◽

Foramen Magnum ◽

Entry Site ◽

Microsurgical Technique ◽

Vessel Injury ◽

Far Lateral ◽

Clear Delineation

OBJECTIVEThe far-lateral and extreme-lateral infrajugular transcondylar–transtubercular exposure (ELITE) and extreme-lateral transcondylar transodontoid (ELTO) approaches provide access to lesions of the foramen magnum, inferolateral to mid-clivus, and ventral pons and medulla. A subset of pathologies in this region require manipulation of the vertebral artery (VA)–dural interface. Although a cuff of dura is commonly left on the VA to avoid vessel injury during these approaches, there are varying descriptions of the degree of VA-dural separation that is safely achievable. In this paper the authors provide a detailed histological analysis of the VA-dural junction to guide microsurgical technique for posterolateral skull base approaches.METHODSAn ELITE approach was performed on 6 preserved adult cadaveric specimens. The VA-dural entry site was resected, processed for histological analysis, and qualitatively assessed by a neuropathologist.RESULTSHistological analysis demonstrated a clear delineation between the intima and media of the VA in all specimens. No clear plane was identified between the connective tissue of the dura and the connective tissue of the VA adventitia.CONCLUSIONSThe VA forms a contiguous plane with the connective tissue of the dura at its dural entry site. When performing posterolateral skull base approaches requiring manipulation of the VA-dural interface, maintenance of a dural cuff on the VA is critical to minimize the risk of vascular injury.

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Surgical Anatomy of the Vertebral Artery at the Skull Base

The Laryngoscope ◽

10.1288/00005537-199207000-00015 ◽

1992 ◽

Vol 102 (7) ◽

pp. 829-831 ◽

Cited By ~ 3

Author(s):

Clarence T. Sasaki ◽

Steven Sims ◽

Paul Drago ◽

Edward McNelis

Keyword(s):

Vertebral Artery ◽

Skull Base ◽

Surgical Anatomy

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Endoscope-assisted far-lateral transcondylar approach for craniocervical junction chordomas: a retrospective case series and cadaveric dissection

Journal of Neurosurgery ◽

10.3171/2020.9.jns202611 ◽

2021 ◽

pp. 1-12

Author(s):

Arianna Fava ◽

Paolo di Russo ◽

Valentina Tardivo ◽

Thibault Passeri ◽

Breno Câmara ◽

...

Keyword(s):

Vertebral Artery ◽

Tumor Resection ◽

Case Series ◽

Craniocervical Junction ◽

Anatomical Landmarks ◽

Total Resection ◽

Female Ratio ◽

Cadaveric Dissection ◽

Transcondylar Approach ◽

Far Lateral

OBJECTIVE Craniocervical junction (CCJ) chordomas are a neurosurgical challenge because of their deep localization, lateral extension, bone destruction, and tight relationship with the vertebral artery and lower cranial nerves. In this study, the authors present their surgical experience with the endoscope-assisted far-lateral transcondylar approach (EA-FLTA) for the treatment of CCJ chordomas, highlighting the advantages of this corridor and the integration of the endoscope to reach the anterior aspect and contralateral side of the CCJ and the possibility of performing occipitocervical fusion (OCF) during the same stage of surgery. METHODS Nine consecutive cases of CCJ chordomas treated with the EA-FLTA between 2013 and 2020 were retrospectively reviewed. Preoperative characteristics, surgical technique, postoperative results, and clinical outcome were analyzed. A cadaveric dissection was also performed to clarify the anatomical landmarks. RESULTS The male/female ratio was 1.25, and the median age was 36 years (range 14–53 years). In 6 patients (66.7%), the lesion showed a bilateral extension, and 7 patients (77.8%) had an intradural extension. The vertebral artery was encased in 5 patients. Gross-total resection was achieved in 5 patients (55.6%), near-total resection in 3 (33.3%), and subtotal resection 1 (11.1%). In 5 cases, the OCF was performed in the same stage after tumor removal. Neither approach-related complications nor complications related to tumor resection occurred. During follow-up (median 18 months, range 5–48 months), 1 patient, who had already undergone treatment and radiotherapy at another institution and had an aggressive tumor (Ki-67 index of 20%), showed tumor recurrence at 12 months. CONCLUSIONS The EA-FLTA provides a safe and effective corridor to resect extensive and complex CCJ chordomas, allowing the surgeon to reach the anterior, lateral, and posterior portions of the tumor, and to treat CCJ instability in a single stage.

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Vertebral Artery Surgery - An Overview of Techniques and Discussion Points for the Future

European Neurological Review ◽

10.17925/enr.2011.06.03.193 ◽

2011 ◽

Vol 6 (3) ◽

pp. 193

Author(s):

Bernard George ◽

Keyword(s):

Vertebral Artery ◽

Jugular Foramen ◽

Craniocervical Junction ◽

Foramen Magnum ◽

Surgical Anatomy ◽

Surgical Approaches ◽

Arteriovenous Fistulas ◽

Intermittent Compression ◽

Safety And Reliability ◽

And Control

The vertebral artery (VA) is an important vessel supplying the hind brain; its surgical exposure and control is usually considered a great challenge. In fact, with good knowledge of surgical anatomy and proper surgical technique, the VA can be controlled and occasionally repaired with safety and reliability. VA exposure is useful in many instances and helps attain better results in the surgical treatment of many different pathologies at any level all along its course in the neck and the skull. These pathologies include intrinsic lesions (atherosclerosis, aneurysms, arteriovenous fistulas), intermittent compression by osteophytes or fibrous bands, and permanent compression mostly by different types of tumours. VA exposure also helps to achieve better treatment of spondylotic myelopathy (by oblique corpectomy) and of tumours at the craniocervical junction, foramen magnum and jugular foramen level. Based on the experience of more than 1,600 surgical approaches, VA surgery is associated with a very limited morbidity and mortality.

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Myopericytoma at the Craniocervical Junction: Clinicopathological Report and Review of a Rare Perivascular Neoplasm

Neurosurgery ◽

10.1093/neuros/nyy262 ◽

2018 ◽

Vol 85 (2) ◽

pp. E360-E365 ◽

Cited By ~ 1

Author(s):

Jimmy C Yang ◽

Andrew S Venteicher ◽

Matthew J Koch ◽

Christopher J Stapleton ◽

Gabriel N Friedman ◽

...

Keyword(s):

Vertebral Artery ◽

Soft Tissues ◽

Craniocervical Junction ◽

Vascular Lesion ◽

Gross Total Resection ◽

Total Resection ◽

Cellular Environment ◽

Close Proximity ◽

The Central Nervous System ◽

Far Lateral

Abstract BACKGROUND AND IMPORTANCE Myopericytoma is an emerging class of neoplasm originating from the perivascular myoid cellular environment, previously classified as a variant of hemangiopericytoma. Most reported myopericytomas are found in soft tissues of the extremities; however, infrequent cases are described involving the central nervous system. Intracranial myopericytoma remains rare. Here, we describe the first report of myopericytoma occurring at the cervicomedullary junction in close proximity to the vertebral artery, mimicking a vascular lesion. CLINICAL PRESENTATION A 64-yr-old woman presented with radiating neck pain. Magnetic resonance imaging revealed a well-circumscribed enhancing lesion adjacent to the vertebral artery-accessory nerve complex. She underwent a far lateral craniotomy and cervical laminectomy to obtain proximal vertebral artery control and adequate exposure of the lesion, which appeared most consistent with neoplasm at surgery. Histopathology revealed a grade I myopericytoma. A gross total resection was achieved, and the patient has no evidence of recurrence 3 yr after surgery. CONCLUSION Tumors of perivascular origin include hemangiopericytoma, glomus tumor, myofibroma, and myopericytoma and are uncommon lesions intracranially. Consideration of and distinction among these perivascular tumors is critically important, as they each have distinct clinical behaviors and management. Myopericytoma can mimic other neoplastic and cerebrovascular pathologies, but it most commonly has a benign course and can be surgically cured if a gross total resection can be achieved. Rarer myopericytoma variants that adopt a more malignant course have been described, and ongoing molecular studies may identify mutations or activated signaling pathways that can be targeted to offer chemotherapeutic options in the future.

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Foramen Magnum Meningioma: Far Lateral Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1695701 ◽

2019 ◽

Vol 80 (S 04) ◽

pp. S363-S364

Author(s):

Ciro Vasquez ◽

Alexander Yang ◽

A. Samy Youssef

Keyword(s):

Vertebral Artery ◽

Cranial Nerves ◽

Mass Effect ◽

Craniocervical Junction ◽

Foramen Magnum ◽

Lateral Approach ◽

Neurological Deficits ◽

Occipital Condyle ◽

Far Lateral Approach ◽

Far Lateral

We present a case of a foramen magnum meningioma in a 42-year-old female who presented with headaches for 2 years, associated with decreased sensation and overall feeling of “heaviness” of the right arm. The tumor posed significant mass effect on the brainstem, and given the location of the tumor in the anterolateral region of the foramen magnum, a right far lateral approach was chosen. The approach incorporates the interfascial dissection technique to safely expose and preserve the vertebral artery in the suboccipital triangle. After drilling the posteromedial portion of the occipital condyle and opening the dura, the tumor can be entirely exposed with minimal retraction on the cerebellum. The working space offered by the far lateral approach allows careful dissection at the lateral craniocervical junction, and preservation of the V4 segment of the vertebral artery and the lower cranial nerves. Simpson's grade-2 resection was achieved with coagulation of the dural base around the vertebral artery. The postoperative course was unremarkable for any neurological deficits. At the 2-year follow-up, imaging identified no recurrence of tumor and the patient remains asymptomatic.The link to the video can be found at: https://youtu.be/IMN1O7vO5B0.

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Resection of a Meningioma at Craniocervical Junction through Far Lateral Approach: Two-Dimensional Operative Video

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1700509 ◽

2019 ◽

Vol 80 (S 04) ◽

pp. S358-S359

Author(s):

Yong Yan ◽

Hongxiang Wang ◽

Tao Xu ◽

Zhenyu Gong ◽

Fan Hong ◽

...

Keyword(s):

Vertebral Artery ◽

Medulla Oblongata ◽

Posterior Inferior Cerebellar Artery ◽

Craniocervical Junction ◽

Lateral Approach ◽

World Health ◽

Neurological Deficits ◽

Who Grade ◽

Far Lateral Approach ◽

Far Lateral

Tumors located in the craniocervical junction region are significantly challenging for surgical resection. We shared our experience of a meningioma at craniocervical junction resected through far lateral approach in a 68-year-old female. The patient presented with intermittent headache with discomfort in the neck and shoulders for 3 years without any positive signs. Magnetic resonance imaging (MRI) revealed a tumor of 3.6 cm × 3.0 cm × 2.5 cm lying at the ventral side of medulla oblongata, with T1 hypointensity, T2 hyperintensity, and a significant enhancement on T1-contrast image. The far lateral approach on the right side was planned to resect the tumor with a park-bench position. The patient underwent a standard craniotomy using a lazy S-shaped incision. The transposition of vertebral artery was performed carefully therein, followed by removal of part of the arches of atlas and axis. After exposure of the tumor, vertebral artery (VA) and posterior inferior cerebellar artery (PICA) adhesive to the lesion could be seen operatively. Truncating the supplying blood vessels of the tumor was taken as the first step, followed by resecting the tumor mass in a piecemeal manner. While preserving VA, PICA, posterior nerves, medulla oblongata, and cervical cord, gross-total resection was achieved under the careful operation. The patient tolerated the procedure well without any neurological deficits. Histological examination confirmed the tumor as a meningioma (World Health Organization [WHO] grade I). Postoperative MRI scan depicted complete resection of the tumor. The patient remained symptom free without any evidence of recurrence during the follow-up period of 1 year. Informed consent was obtained from the patient.The link to the video can be found at: https://youtu.be/i9H-wS4fF10.

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