Vertebral Artery Variations at the Craniovertebral Junction in “Sandwich” Atlantoaxial Dislocation Patients

Objective: To summarize the vertebral artery (VA) pattern of 96 “sandwich” atlantoaxial dislocation (AAD) patients and to describe the strategies of reducing the injury of VA during surgery.Methods: From 2009 to 2020, we retrospectively reviewed the 3-dimensional computed tomography angiography data of 96 AAD patients combined with atlas occipitalization and C2–3 fusion, which were diagnosed as “sandwich” AAD and 96 patients as control group patients who were without atlas occipitalization, C2–3 fusion and any other cervical bone deformity at our institution. The variations of each side of VA were described in 3 different parts (C0–1, C1–2, and C2–3) according to the characteristics of the 3-part pathological structures in “sandwich” subgroup.Results: One hundred ninety-two sides of VAs in every group of patients were analyzed and every VA was described separately at 3 different level regions. There were different variations in these 3 different regions: 4 variations in the upper fusion region, 5 variations in the sandwiched region, and 6 variations in the lower fusion region in sandwich AAD patients. And the rate of VA deformity in sandwich AAD patients was much higher and more types of VA variations existed.Conclusion: In “sandwich” AAD patients, deformities of vertebral arteries in craniovertebral junction are more common, and the same VA may have deformities at different levels that severely affect surgical procedures. Therefore, preoperative imaging examination of VA for “sandwich” AAD patients is vital of guiding surgeons to avoid injury of VA during surgery.

Transection of the Common Carotid and Vertebral Arteries Following a Penetrating Neck Injury

A case of a 30-year-old man who was admitted following a penetrating neck injury is presented. A clinical examination and operative findings identified semi-comatose mentality, neck muscle laceration, and transection of the left common carotid and vertebral arteries and the internal jugular vein. During the operation, the carotid arteries were repaired by interposition grafting, and the internal jugular vein was ligated. The vertebral artery was managed by interventional embolization. Although the patient had some neurological deficit, he was discharged on postoperative Day 52. This surgical case prompted a discussion regarding neurological outcomes, and surgical and endovascular treatment following vascular neck injury.

Bilateral typeIIpersistent proatlantal intersegmental artery: a rare variant of persistent carotid-vertebrobasilar anastomoses

The persistent proatlantal intersegmental artery is a rare variant of persistent carotid-vertebrobasilar anastomoses, especially their bilateral presence is rarer. We report a case of bilateral typeII persistent proatlantal intersegmental artery. The absence of bilateral vertebral arteries was incidentally noted on neck ultrasound examination. Subsequent time-of-flight MR angiography confirmed this. The bilateral typeIIpersistent proatlantal intersegmental artery arose from the cervical external carotid artery, penetrated the C1 transverse foramen, entered the skull via the foramen magnum, and joined the lower portion of the basilar artery.

Cerebral Blood Flow Volume in Posterior Circulation Ischemic Disorders

Objective: The aim of this study was to determine blood flow volume (BFV) in the normal state and its features in patients with acute posterior circulation ischemic strokes (PCIS) and vertebrobasilar insufficiency (VBI) using color duplex sonography (DS).Methods: The study included DS data from 96 patients with verified PCIS (66 men and 30 women, aged 64±13 years) and 29 adults with VBI (17 men and 12 women, aged 66±11 years). The control group consisted of 65 healthy male volunteers of different ages.Results: In asymptomatic healthy volunteers, there was a significant decrease in BFV in the internal carotid artery (ICA) with age (502 ml/min in young people, 465 ml/min in the older subgroup) with rS = −0.24 ( p = 0.05), and the aggregated BFV in the vertebral arteries (VAs) turned out to be almost constant (141–143 ml/min). In patients with VBI, the aggregated BFV in the VAs (144 ml/min) did not differ from that in healthy volunteers, but the BFV values in the ICAs were significantly lower (325 ml/min). In patients with PCIS, the aggregated BFV in the ICAs was also significantly lower (399 ml/min) than in the control group but did not significantly differ from that in patients with VBI. In patients with PCIS, there was a significant decrease in the aggregated BFV in the VAs (105 ml/min), which distinguished this group from other examined patients.Conclusions: A significant decrease the BFV in the VA was observed only in patients with PCIS and was associated with the presence of steno-occlusive diseases (SOD) more often in the left VA. Patients with VBI had the most pronounced decrease in BFV in the ICA.

Abstract 1122‐000114: Blunt Traumatic Vertebral Artery Injury: Incidence, Treatment, and Outcomes

Introduction : Blunt cerebrovascular injury (BCVI) refers to any injury to the carotid or vertebral arteries sustained via blunt trauma. Computed tomographic angiography (CTA) has become a standard and widely available screening tool for BCVI, often allowing injuries to be detected on admission. Prior research has shown that BCVI is associated with subsequent stroke. Treatment protocols vary by institution, and the optimal treatment method for these injuries is not standardized. Methods : This research was approved by the IRB. All patients presenting to a level 1 trauma center from 2011 to 2018 were screened for inclusion using the Primordial Database imaging report search tool (San Mateo, CA). All included patients underwent CTA within 24 hours of presentation. Patients were excluded if they had penetrating injury, age <16 years, or concomitant carotid injury. Data was retrospectively collected. Injuries were graded according to the criteria of Biffl et al. Treatment and follow up imaging of BCVI was determined by the vascular neurosurgeon on call. Results : A total of 2819 patients underwent screening CTA, with 156 patients (5.5%) identified with isolated vertebral artery injuries. Sixteen patients (10%) had bilateral vertebral artery injuries, for a total of 172 injured vertebral arteries. There was a male predominance (n = 97, 62%). Ninety‐two patients (59%) had a cervical spine fracture at the level of injury. Three posterior circulation strokes were detected, all within 24 hours of admission, prior to starting any treatment. Treatment regimens included aspirin (n = 135 vessels), clopidigrel (n = 1), anticoagulation (n = 2), or no treatment (n = 18). Follow up imaging was available for 84 patients (98 arteries). Three patients had worsening Biffl grade on follow‐up CTA, and the remainder were stable or improved. The three worsened injuries were all grade 2 on initial presentation. Conclusions : In our patient population, isolated blunt vertebral artery injuries were treated with multiple regimens. The majority of patients in our group were treated with aspirin; no strokes were detected after the initiation of therapy, regardless of the treatment modality or the fate of the injured. Our study is not randomized and the treatment groups are not evenly distributed. Further investigation is required to address the optimal method and duration of treatment for blunt vertebral artery injury. However, our data suggest that aspirin alone may be sufficient therapy for isolated vertebral artery injuries.

The potential of duplex scanning in the diagnosis of pathological tortuosity of the vertebral artery

Aim. To assess the capabilities of duplex scanning and study the features of hemodynamics in the vertebral arteries before and after surgical treatment.Material and methods. The results of anatomical and circulatory characteristics of an extracranial segment of the vertebral arteries in 52 patients with various forms of pathological tortuosity were analyzed. Kinking was present in 38 patients, coiling in 8 patients, and Powers anomaly in 6 patients. There were 18 men and 34 women. The mean age of the patients was 45.6±8.7 years.Results and discussion. In all types of PT of VA with ostium stenosis, the diameter of the artery was decreased, and based on tortuosity it contributed both to the reduction and deterioration of arterial blood flow to the vertebrobasilar basin. The decrease or increase in the linear velocity of blood flow, as well as other blood flow parameters, depended on both the type of pathological tortuosity of the PA and on the vessel diameter and the value of angulation. Hypoplasia of the opposite vertebral artery also occurred in 28 patients, which resulted in impaired blood supply to the brain.Vascular examination after reconstructive surgeries resulted in normalization of the parameters of arterial circulation and cerebral perfusion. Primary vascular patency was 96.2%, restenosis was not revealed in any observation.Conclusion. Duplex scanning is a highly informative technique for both diagnosing pathological deformities of the vertebral arteries and assessing the restoration of the hemodynamics of the vertebrobasilar system after reconstructive surgery. This method provides the most accurate information on the anatomical form and localization of pathological deformities of the vertebral artery. It also allows quantitative assessment of cerebral blood flow.

Anomalies of the cerebral arteries in military servants - participants of ATO-OOS, who suffered ischemic strokes

The analysis of medical histories of 129 patients aged 20 to 59 years, who suffered acute cerebrovascular disorders (AСVD) of the ischemic type (IT), and participated in ATO-JFO was carried out. Anomalies of cerebral arteries were found in all of them. A significant role of hypoplasia of the right posterior cerebral artery, aplasia of the posterior connective, left anterior cerebral and anterior connective, as well as pathological S-shaped tortuosity of the internal carotid artery, hypoplasia of the vertebral arteries and their combinations in the development of acute cerebrovascular disorders in ATO members was established.

Secondary prevention of cerebrovascular events in patients with “asymptomatic” atherosclerotic stenosis of the vertebral arteries

Aim To determine the feasibility of performing endovascular interventions in patients with “asymptomatic” atherosclerotic stenosis of the vertebral arteries, as a method of secondary prevention of cerebrovascular events. Material and methods The patients were randomized into 2 groups: in group I (n=78), secondary prevention of cerebrovascular events were carried out in a combined strategy - stenting of the vertebral arteries in combination with medication therapy, and in group II (n=78) - only medication therapy. Group I were randomized in 2 subgroups – Ia and Ib. In subgroup Ia (n=39) – endovascular intervention were performed with embolism protection devices, and in subgroup Ib (n=35) - embolism protection devices were not used. Long-term follow-up was planned after 12, 24 and 36 months. Inclusion criteria: “asymptomatic” stenosis of vertebral arteries 50–95%; the diameter of the vertebral arteries is not less than 3.0 and not more than 5 mm; the presence of not gross cerebral and focal symptoms corresponding to the initial (asymptomatic) stage of encephalopathy (according to E.V. Schmidt). Primary endpoint: total frequency of cerebrovascular events. Results The total incidence of spasm and dissection during endovascular intervention was 20.5% in subgroup Ia and 2.5% in subgroup Ib (p=0.0367). Also in subgroup Ia, 2 (4.5%) patients had transient ischemic attack. In subgroup Ib, perioperative cerebrovascular events was not observed. The total frequency of major cerebral complications over 36 months of follow-up was 4.5% in group 1 and 37.5% in group II (χ2=15.101; p&lt;0.0001). The frequency of cardiac events was 9.1 and 19.6%, respectively, to groups I and II (χ2=14.784; p&lt;0.0001). These indicators were obtained against the background of high patient adherence to treatment and high rates of achieving tough target lipid values. Restenosis of the stents was observed in general, in 18% of patients from group I, who underwent stenting of the vertebral arteries by various generations of stents. Moreover, restenosis alone did not affect the incidence of major cerebral complications in the long-term period (χ2=0.1643; p=0.735). Conclusion In spite of the development of restenosis, it is endovascular intervention in combination with drug therapy that helps to avoid the development of large cerebrovascular events arising from the instability of atherosclerotic plaque in patients with “asymptomatic” vertebral artery stenosis and is a reliable method of secondary prevention of of cerebrovascular events. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian academic excellence project 5-100

Hemodynamics disorders in vertebra-basilar region in patients with vibration disease, caused by local vibration (data of rheography and transcranial dopplerography)

Brain hemodynamics was studied in vertebra-basilar region in patients with vibration disease, resulting from local vibration. High percentage of clinical and roentgenologic manifestations of cervical octeochondrosis was revealed, as well as incidence increase of cephalgia syndrome while vibration disease progressing. Analysis of rheographic curves (deviation by E.Enin) and transcranial dopplerosonograms showed cerebral circulation dificiency in vertebrabasilar region. The highest level of hemodynamic disorders was marked in vertebral arteries. It is not excluded, that one of the factors, enfluencing hemodynamics disorders, is pathology of the vertebral column.