A case of vertebral artery dissection with lateral inferior pontine syndrome and lateral medullary syndrome

BACKGROUND: The Iceman is a prehistoric, completely preserved, 5300-year-old male human mummy. OBJECTIVE: To obtain the first biopsy specimens from inside the Iceman while meeting an extended standard of hygiene and following precise intraoperative guidance to the site of biopsy and keeping tissue damage to a minimum. DESIGN: Biopsy specimens from the nose, the maxillary sinus, and the larynx of the Iceman were obtained. Special caution had to be taken while performing the biopsies to not contaminate the Iceman with heavy metals or remnants of microorganisms. SUBJECT: The Iceman, a cadaver kept frozen in a glacier for 5300 years. The Iceman is in an excellent state of preservation and will allow fundamental histological, morphological, and molecular genetic insights into early man. INTERVENTION: The biopsies were planned and executed with the aid of Interventional Video Tomography, a system that guides the surgeon to the target area by combining live video with existing imaging modalities. The system does not need mechanical fixation of the subject (the Iceman) and is barely in physical contact with the subject; thus, it was the ideal tool for guiding the surgeon to the site of the biopsy samplings through a tiny canal into the nose, the maxillary sinus, and the larynx of the Iceman. RESULTS: We have obtained a number of tissue samples by precisely guided 3-dimensional navigation. Unnecessary tissue damage was avoided. CONCLUSIONS: Visual inspection of the extracted mucosa showed typical human cadaver tissue, despite its age, without clinical abnormalities. Currently, the samples are being investigated by various international scientific groups.     

Unilateral posterior spinal artery syndrome of the upper cervical cord associated with vertebral artery occlusion

Upper cervical cord infarction in the territory of the posterior spinal artery is very rare. We present here an elderly man who developed right upper cervical (C1-2) posterior spinal artery syndrome associated with vertebral artery occlusion. A 62-year-old man suffered a right upper cervical (C1-2) posterior spinal artery syndrome. The onset was associated with neck flexion. Magnetic resonance imaging clearly showed an ischemic lesion. Cerebral angiography revealed occlusion of the distal end of an ipsilateral vertebral artery. The occlusion of the vertebral artery probably caused the cervical cord infarction. The neck flexion possibly induced thrombogenesis in the vertebral artery. Unilateral upper cervical posterior spinal artery syndrome associated with vertebral occlusion following neck flexion was suggested.     

Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency

OBJECTIVE: Symptomatic dynamic changes in blood flow secondary to vertebral artery compression with rotational head motion are evaluated in a series of patients as a cause for posterior circulation transient ischemic attacks. These cases are classic examples of rotational vertebral artery occlusion and allow for the discussion of the anatomic basis, angiographic features, and treatment options. ILLUSTRATIVE CASES: In our series, symptoms of vertebrobasilar insufficiency were reproducible with rotational head movement. Compression of the vertebral artery was demonstrated angiographically. The correct site of occlusion of the vertebral artery was apparent only by dynamic angiography with progressive head rotation. All of the patients presented in the illustrative cases had occlusion at the C2 level; however, one patient had been previously misdiagnosed and another had an additional site of occlusion. The anatomic course of the vertebral artery is described in addition to the sites of rotational occlusion. CONCLUSION: Rotational vertebral occlusion is an important cause of vertebrobasilar symptoms, which may lead to permanent neurological deficit if left undiagnosed. Dynamic angiography is the established method of diagnosis. Great care must be taken to avoid misdiagnosing the site of occlusion or missing a second occlusive site. For this reason, it is crucial to have a thorough understanding of the anatomic course of the vertebral artery and the muscular and tendinous insertions, which may cause rotational occlusion. The decision for treatment must be based on the site of occlusion as well as the assessment of the patient as a surgical candidate. A review of the literature reveals that surgical treatment is effective and must be considered to avoid further morbidity.     

Development of a dissecting aneurysm on the vertebral artery immediately after occlusion of the contralateral vertebral artery: a case report

A 49 year old female presented with subarachnoid hemorrhage due to a ruptured dissecting aneurysm on the left vertebral artery (VA). Following an occlusion test, we performed proximal occlusion of the left VA with detachable balloons. However, a dissecting aneurysm on the right VA developed three weeks later. After an occlusion test had showed no change in cerebral blood flow, auditory brain stem response, or neurological status, proximal occlusion of the right VA was performed. The patient has returned to normal life without neurological deficits. Bilateral dissecting aneurysms of the VA are quite common, but de novo VA dissecting aneurysms or enlargement of such aneurysms after occlusion of contralateral VA are rare. This case suggests that hemodynamics stress may be a causal factor in the development of VA dissecting aneurysms. Careful pre- and post-operative neuroradiological examination of the contralateral VA are required in patients undergoing VA occlusion for dissecting aneurysms.     

Hemodynamics in an arterial union--simulation study on therapeutic unilateral vertebral artery occlusion

Hemodynamic changes following unilateral vertebral artery (VA) occlusion were investigated in a rat model. The left carotid artery was resected and anastomosed to the right side in an end-to-side fashion to create a half-ring bypass. The distal side of the bypass was regarded as a union of VAs. Changes in the geometry, histology and hemodynamics in the union were investigated after the recipient artery was ligated. Intimal thickening was most prominently observed in the recipient arterial segment distal to the ligation site, where the lumen was obliterated. However, the portion of the lumen within 2.6 +/- 0.6 (mean +/- s.d.) mm, a distance of 2.9 +/- 0.6 times the internal diameter from the union, was not obliterated. The angle of the union was positively related to the length of this residual lumen. The results of this study explain some of the pathogenesis in unsuccessful aneurysmal thrombosis or brain stem infarction after therapeutic unilateral VA occlusion.     

Surgical treatment of partial extraluminal occlusion of first part of vertebral artery

This report presents the clinical concept of hindbrain ischemia due to partial extraluminal occlusion of a segment of the first part of the vertebral artery, and submits a definite method of surgical treatment. Thirty one patients with vertebral artery insufficiency are presented who had operations with striking post-operative symptomatic improvement. Operative selection of patients is dependent on aortic arch angiography with visualization of the neck vessels. There was no mortality and no significant morbidity in this series.     

Anterior spinal artery syndrome associated with severe stenosis of the vertebral artery

We describe a 55-year-old man with quadriparesis and impaired pain and temperature sensation in whom T2-weighted MR images revealed a high-intensity lesion in the cord at C3-4. Angiography showed occlusion of the right vertebral artery and severe stenosis of the left vertebral artery. We concluded that the stenosis of the vertebral artery led to the anterior spinal artery syndrome and to a disturbance of consciousness.     

Spontaneous bilateral carotid and vertebral artery dissection presenting as a Collet-Sicard syndrome

Spontaneous dissection of the internal carotid arteries usually presents with unilateral headache, neck pain, focal ipsilateral cerebral ischaemic symptoms and a Horner's syndrome. Lower cranial nerve palsies are only rarely observed. We report a case of carotid and vertebral dissections presenting as a unilateral palsy of the ninth to twelfth cranial nerves (Collet-Sicard syndrome).     

Rheumatoid arthritis and vertebral artery occlusion: a case report with angiographic and magnetic resonance demonstration

A 40-year-old woman with rheumatoid arthritis (RA) who presented with vertigo and nausea, was found to have left vertebral artery occlusion on angiography. There was minimal atlantoaxial subluxation and no odontoid herniation. Magnetic resonance imaging (MRI) was suggestive of a left vertebral artery dissection. This is the first report of MRI of vertebral artery occlusion in RA. It will be important to accumulate MR images of this complication in future cases.     

Cervical infarction associated with vertebral artery occlusion due to spondylotic degeneration: case report

Cases of cervical infarction with clearly documented evidence of the underlying aetiology and associated neuroradiological abnormalities have not been frequently reported. A rare case of cervical infarction caused by midvertebral artery occlusion due to spondylotic degeneration of the spine is described. The most probable aetiological factor affecting this disease entity, and the usefulness of magnetic resonance imaging in the detection of this rare lesion, are briefly discussed.     

Central retinal vein occlusion combined with occlusion of a cilioretinal artery. A case report

An otherwise healthy 39-year-old man with a dark spot in the visual field of his left eye showed retinal whitening, indicating a cilioretinal arterial obstruction and minor signs of venous stasis at the initial examination. The affected cilioretinal artery filled normally during fluorescein angiography. The visual acuity was 1.0 bilaterally. One week later, the retinal whitening had decreased and signs of central retinal venous occlusion (venous dilatation, retinal haemorrhages and papillary oedema) predominated in the fundus picture. The patient was treated with oral betamethasone and acetylsalicylic acid. The patient was free of symptoms and the fundus normalized within 10 months. The pathogenesis of cilioretinal arterial obstruction combined with central retinal venous occlusion is not established. The clinical course in this case seems to favour a hypothesis of a primary arterial affection.     

Extracranial vertebral artery aneurysm complicating Klippel-Feil syndrome: case report]

The Klippel-Feil syndrome is one of the spinal malformations characterized by fusion of the cervical vertebrae. It is well known that the malformation can cause some neurologic disorders. However, an aneurysm in the vertebral artery associated with the Klippel-Feil syndrome is extremely rare, with only one case having been reported in the literature. We present a 39-year-old female with a sudden onset of disturbed consciousness. Lateral cervical x-ray films showed the Klippel-Feil syndrome and hypermobility between C1 and C2. MRI showed multiple infarctions in the posterior circulation, including bilateral thalami. Right vertebral angiogram identified the extracranial vertebral artery aneurysm as the source of the emboli. The patient gradually recovered with conservative therapy. The aneurysm was thought to be produced by chronic arterial trauma secondary to excessive movement between C1 and C2. We conclude that an extracranial vertebral artery aneurysm is a serious complication in a patient with the Klippel-Feil syndrome.     

Bilateral vertebral artery dissection in a patient with afibrinogenemia

BACKGROUND: Afibrinogenemia, a rare coagulation disorder, has not been associated with vertebral artery dissections. CASE DESCRIPTION: A 28-year-old woman with afibrinogenemia developed spontaneous neck pain followed by a right medullary infarction, and MR angiography showed extensive bilateral vertebral artery dissection. She was treated with fibrinogen replacement and anticoagulants and showed a favorable evolution, with only mild residual right upper arm incoordination. CONCLUSIONS: In this patient spontaneous bilateral vertebral artery dissection complicated afibrinogenemia. Since anticoagulant therapy is usually indicated for arterial dissection, this association created a therapeutic problem. This patient received anticoagulants with fibrinogen replacement, which resulted in a favorable evolution.     

Anaesthesia in a child with Patau's syndrome

A 5-year-old girl who had Patau's syndrome associated with double outlet right ventricle and pulmonary stenosis required general anaesthesia for the formation of a modified Blalock-Taussig shunt.     

Spontaneous thrombosis of a basilar artery traumatic aneurysm in a child

Traumatic aneurysms are rare and occur most commonly in young adults; however, the relative frequency in the pediatric population is high, owing to the low prevalence of congenital saccular aneurysms in children. Traumatic aneurysms typically involve the anterior circulation, and spontaneous thrombosis is uncommon; hence, surgery is usually necessary. We present a case of a posttraumatic aneurysm in a child that occurred after a fall from a large height and that spontaneously thrombosed.     

Ulnar artery occlusion in mountain bikers

We report two cases of the hypothenar hammer syndrome, diagnosed with digital angiography, which occurred in mountain bikers. To our knowledge, the association between mountain bike enthusiasts and ulnar artery occlusion has not been reported in the literature.