Delineability and anatomical variations of perforating arteries from normal vertebral artery on 3D DSA: implications for endovascular treatment of dissecting aneurysms

Tanoue, Shuichi; Endo, Hidenori; Hiramatsu, Masafumi; Matsumaru, Yuji; Matsumoto, Yasushi; Sato, Kenichi; Tsuruta, Wataro; Sato, Masayuki; Hirohata, Masaru; Abe, Toshi; Kiyosue, Hiro

doi:10.1007/s00234-020-02549-y

Cited by 16 publications

(4 citation statements)

References 27 publications

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“…Tanoue et al evaluated anatomical variations of perforating arteries from VA using threedimensional DSA. They found that non-PICA VAs give off a larger number of perforators than other types, indicating a higher risk of ischemic stroke with trapping (11). In our case, the left PICA was Cerebral hyperperfusion syndrome (CHS) after angioplasty or stenting for intracranial artery stenosis is a rare but severe complication.…”

Section: Discussionmentioning

confidence: 64%

Case report: Medulla oblongata and cervical cord reperfusion injury after intracranial vertebral artery angioplasty and stenting

et al. 2023

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BackgroundWhite cord syndrome is an uncommon complication characterized by delayed neurologic deterioration with no other identified cause after spinal decompression surgery. Its etiology is attributed to spinal cord reperfusion injury. Here, we present the first case of an extended version of white cord syndrome, with concomitant involvement of the medulla oblongata and cervical cord reperfusion injury after intracranial vertebral artery angioplasty and stenting.Case presentationA 56-year-old male suffered an ischemic stroke in the right anteromedial medulla oblongata. Angiography revealed bilateral vertebral artery stenosis in the intracranial segment. We performed elective left vertebral artery angioplasty and stenting. An intraoperative flow arrest in the left VA occurred and was stopped after the withdrawal of the catheter. Several hours after the operation, the patient developed occipital headache, back neck pain, dysarthria, and worsening left-sided hemiplegia. Magnetic resonance imaging revealed hyperintensity and swelling in the medulla oblongata and cervical cord, in addition to small medullary infarction. A digital subtraction angiography revealed intact vertebrobasilar arteries and patency of the left vertebral artery, left posterior inferior cerebellar artery, and implanted stent. We considered that the reperfusion injury had caused the complication. After treatment, the patient’s symptoms and neurologic deficits greatly improved. He achieved a favorable outcome at the 1-year follow-up, with normal intensity restored in the medulla oblongata and cervical cord on magnetic resonance imaging.ConclusionConcomitant reperfusion injury in the medulla oblongata and cervical cord secondary to vertebral artery angioplasty and stenting is extremely rare. However, this potentially devastating complication requires early recognition and prompt treatment. Maintaining the antegrade flow during vertebral artery endovascular treatment is a precaution against reperfusion injury.

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Section: Discussionmentioning

confidence: 64%

Case report: Medulla oblongata and cervical cord reperfusion injury after intracranial vertebral artery angioplasty and stenting

et al. 2023

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“…Also, Tanoue et al reported a radiological study of anatomical variations in perforating arteries from the VA. Non-PICA-type VAs give off more perforators than other types. This indicates that the trapping of non-PICA-type VAs is associated with a risk of ischemic complications [ 10 ]. In addition, Aihara et al reported that proximal to PICA or non-PICA-type VADA presented a higher incidence of medullary infarction because proximal VA stump could not provide sufficient flow to small arteries branching from VA [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

“…These fine branches are not readily depicted on conventional angiography, such as in this case. However, recent advances in angiographic apparatus may provide high-resolution radiological and reconstructed images of three-dimensional rotational angiography to evaluate tiny perforating arteries [ 10 , 11 ]. In addition, adequate timing, volume, and injection rate of contrast medium in rotational angiography are important for obtaining precise images.…”

Section: Discussionmentioning

confidence: 99%

Severe Complications After Endovascular Trapping of Vertebral Artery Dissecting Aneurysm: Simultaneous Occurrence of Medullary and Cervical Spinal Cord Infarction

Matsubara¹

2022

Cureus

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Endovascular trapping of vertebral artery dissecting aneurysm (VADA) can lead to ischemic complications, including medullary infarction due to obstruction of perforating arteries, and cervical spinal cord infarction caused by ischemia of spinal arteries branching from the affected vertebral artery (VA). This report describes a rare case of concomitant medullary and spinal cord infarction following internal trapping of ruptured VADA.A 47-year-old male presented with severe subarachnoid hemorrhage and neurological pulmonary edema, and a vertebral angiogram demonstrated VADA. A small-sized posterior inferior cerebellar artery (PICA) was found proximal to the affected vessel. The anterior spinal artery (ASA) branched distal to a dilated portion. Perforating arteries were insufficiently visualized due to image quality. Internal trapping was performed, and complete occlusion of VADA was achieved, preserving the origin of ASA. Postoperative magnetic resonance imaging (MRI) revealed ischemic lesions in the lateral medulla oblongata and upper cervical spinal cord. The patient presented with severe neurological symptoms, including lower cranial neuropathy due to medulla infarction, respiratory dysfunction, and tetraparesis due to cervical spinal cord infarction. The modified Rankin scale at three months was grade 5.Various factors, including perforating artery ischemia, unstable general condition, and insufficient antithrombotic therapy, were considered the cause. Therefore, evaluating the tiny perforating and spinal arteries branching from the VA should be especially considered to avoid these complications. Furthermore, advances in angiographic apparatus and workstations should provide a high-resolution radiological image and adequate treatment strategy.

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“…Surgical proximal PAO is a reasonable treatment method that can help avoid them and clip the entire vasa vasorum with pinpoint accuracy. Tanoue et al 18 examined the presence of perforating arteries and branching morphology in 120 Japanese patients undergoing 3-dimensional digital subtraction angiography without vertebral artery trunk lesions. In that report, perforating branches of the vertebral artery were distributed ventral to the medulla oblongata, with a terminal branch that ended in the brain parenchyma when it was closer to the union; the perforating branches were distributed laterally and dorsally, with a longitudinal branch that ran along the brain parenchyma in a cephalocaudal direction when it was farther away from the union.…”

Section: Discussionmentioning

confidence: 99%

Single-Center Case Series of Simple Proximal Clipping for Large Thrombosed Vertebral Artery Aneurysms: Preservation of Perforating Arteries and Long-Term Outcomes

Arai

Mizutani²,

Sugiyama³

et al. 2022

Operative Neurosurgery

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BACKGROUND: Surgical proximal parent artery occlusion (PAO) is one of the treatments for partially thrombosed vertebral artery aneurysms (PTVAs). However, whether long-term changes in size and perforating arteries through the blind end can be truly preserved remain unknown. OBJECTIVE: To evaluate the efficacy and safety of surgical proximal PAO for PTVAs, focusing on the transition in size and preservation of perforating arteries. METHODS: We retrospectively reviewed 14 consecutive cases of unruptured large PTVAs. The cases were treated with surgical proximal PAO without trapping or thrombectomy. Preservation of the perforating arteries was confirmed through intraoperative indocyanine green video angiography. The aneurysm size was evaluated by measuring the maximum diameter on axial T2-weighted magnetic resonance images. Post-treatment outcomes were assessed using the modified Rankin Scale at the last follow-up examination. RESULTS: Thirteen patients (excluding 1 with morbidity) had a mean follow-up time of 33.2 months (range, 12-60 months) and a mean reduction rate of 71% (range, 32%-95%). Only 1 patient (7.2%) experienced postoperative stroke, and 13 patients (92.8%) showed no worsening of the modified Rankin Scale score at the final follow-up examination. The symptoms were improved in 5 of the 6 symptomatic patients (83.3%). In 10 patients (71.4%), a perforating branch that could not be identified on preoperative imaging was identified intraoperatively. CONCLUSION: Surgical proximal PAO without trapping or thrombectomy for PTVAs allows long-term reduction of aneurysm size and improves treatment safety by preserving the perforating artery, especially in cases wherein direct reconstruction is not feasible.

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Delineability and anatomical variations of perforating arteries from normal vertebral artery on 3D DSA: implications for endovascular treatment of dissecting aneurysms

Cited by 16 publications

References 27 publications

Case report: Medulla oblongata and cervical cord reperfusion injury after intracranial vertebral artery angioplasty and stenting

Case report: Medulla oblongata and cervical cord reperfusion injury after intracranial vertebral artery angioplasty and stenting

Severe Complications After Endovascular Trapping of Vertebral Artery Dissecting Aneurysm: Simultaneous Occurrence of Medullary and Cervical Spinal Cord Infarction

Single-Center Case Series of Simple Proximal Clipping for Large Thrombosed Vertebral Artery Aneurysms: Preservation of Perforating Arteries and Long-Term Outcomes

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