Tethering of the vertebral artery in the congenital arcuate foramen of the atlas vertebra: a possible cause of vertebral artery dissection in children

Abstract

Twelve children with vertebrobasilar artery stroke are reported (seven males, five females; aged 6 months to 15 years). Patient 1 showed an arcuate foramen in the posterior arch of the atlas, an anatomical variant occurring in 3 to 15% of the population. It was hypothesized that the presence of the arcuate foramen might cause tethering of the vertebral artery and lead to its dissection by repetitive trauma. Lateral plain films of the cervical spine in cases of posterior circulation stroke were taken. Eight of 11 patients showed aberrant arcuate foramina. Of the remaining three patients, one had normal cervical spine X‐rays, one had an absent right posterior arch of the atlas following previous surgery for a cervical meningocele, and one patient had incomplete ossification of the vertebrae. Seven of the nine patients with arcuate foramina had vertebral angiograms. In all cases this showed the vertebral artery passing through the arcuate foramen before entering the brain and an appearance consistent with arterial dissection and occlusion at the same site below the foramen. Most documented cases of posterior circulation stroke in children follow trauma, which may be minimal or repetitive, with thrombotic occlusion of the artery at C1‐C2 level. The association with an arcuate foramen and its possible causative role in the genesis of posterior circulation stroke in children has not been previously recognized. There may be a causal association between the presence of an arcuate foramen, tethering of the vertebral artery in the foramen, and dissection from repetitive trauma with movement of the neck.

Normal anatomy and anatomic variants of vascular foramens in the cervical vertebrae: a paleo-osteological study and review of the literature

“…Other symptoms may include vertigo, vegetative manifestations, auditory disturbance, loss of postural muscle tone, cerebral ischemia, arterial dissection, and rotational vertebral artery occlusion (bowhunter stroke) (Cushing et al 2001;Split and Sawrasewicz-Rybak 2002;Cakmak et al 2005;Brown and Verheyden 2009;Greiner et al 2010;Koutsouraki et al 2010;Taylor et al 2012). In some patients, decompressive procedures may alleviate the symptomatic compression of the vertebral artery in the arcuate foramen (Tubbs et al 2007a).…”

The prevalence of posticus ponticus: retrospective analysis of radiographs from a chiropractic health center

“…[1][2][3][4] There is a significant amount of human research that has been done regarding posticus ponticus in many countries including Turkey, South Africa, Poland, India, New Zealand, France Greece, the United Kingdom, Australia, and the United States. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] It is interesting to note that posticus ponticus research has also been conducted on nonhuman primates. 2 The results of the nonhuman primate research indicated a greater prevalence of posticus ponticus in nonhuman primates vs humans.…”

“…1,3,4,[8][9][10][11][12][13][14][15][16]18,20 The literature suggests that the prevalence of partial posticus ponticus can be up to 35% and that of complete posticus ponticus can be up to 15% in the white population. 1 This study sought to determine the prevalence of posticus ponticus within a sample of chiropractic health center patients.…”

“…Over the years, researchers have investigated the unilateral vs bilateral occurrence of posticus ponticus, 1,3,4,6-8,11,12,18 measured the size of the arcuate foramen formed by it, 4,5,8,14 investigated the occurrence of complete vs incomplete ponticles, 1,[6][7][8]11,12,14,17,19 examined its progressive potential, 1,14,18 correlated patient age or sex to its presence, 1,[3][4][5]8,11,[14][15][16][18][19] examined genetic predisposition of posticus ponticus among family members, 3 and explored the prevalence of posticus ponticus within specific human populations. 1,3,4,[8][9][10][11][12][13][14][15][16]18,20 The literature suggests that the prevalence of partial posticus ponticus can be up to 35% and that of complete posticus ponticus can be up to 15% in the white population.…”

The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation

“…Recent reports suggest an explanation for this inequity is the existence of subpopulations who may be predisposed to mechanical compromise [19] through anatomic [4,34], metabolic [30], or physiological anomalies [24,44]. It is also possible that cSMT may be provided to persons with dissections-in-progress; a subsequent stroke may therefore be circumstantial or aggravated, but not initiated, by cSMT.…”