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Open access

Microvascular decompression of a vertebral artery loop causing cervical radiculopathy: illustrative case

Alexa Semonche, Lorenzo Rinaldo, Young Lee, Todd Dubnicoff, Harlan Matles, Dean Chou, Adib Abla, and Edward F Chang

BACKGROUND

Vertebral artery loops are a rare cause of cervical radiculopathy. Surgical options for nerve root decompression include an anterior or posterior approach, with or without additional microvascular decompression.

OBSERVATIONS

The authors describe a case of a 49-year-old man with a long-standing history of left-sided neck pain and migraines, who was found to have a vertebral artery loop in the left C3–4 neural foramen compressing the left C4 nerve root. The patient underwent a posterior cervical decompression with instrumented fusion and macrovascular decompression of the left C4 nerve root via Teflon felt insertion. In a literature review, we identified 20 similar cases that had also been managed surgically.

LESSONS

Although the anterior approach is more frequently described in the literature, a posterior approach for nerve compression by a vertebral artery loop is also a safe and effective treatment. The authors report the third case of this surgical approach with a good outcome.

Open access

Retrograde thrombectomy of acute common carotid artery occlusion with mobile thrombus: illustrative cases

Yukiya Okune, Hitoshi Fukuda, Toshiki Matsuoka, Yo Nishimoto, Keita Matsuoka, Naoki Fukui, 1 PhD, Satoru Hayashi, Tetsuya Ueba, and 1 PhD

BACKGROUND

Acute embolic occlusion of the common carotid artery (CCA) alone is rare. However, once it occurs, recanalization is challenging due to the large volume of the clot, larger diameter of the CCA, and risk of procedure-related distal embolism into the intracranial arteries.

OBSERVATIONS

The authors report two cases of acute embolic occlusion of CCA alone, caused by a cardiac embolus trapped at the proximal end of a preexisting atherosclerotic plaque at the cervical carotid bifurcation. In both cases, the CCA was successfully recanalized using retrograde thrombectomy in a hybrid operating room. In case 1, a 78-year-old male with acute right CCA occlusion underwent retrograde thrombectomy, where the cervical carotid bifurcation was exposed and incised, and the entire embolus was retrieved with forceps. Despite successful revascularization, massive bleeding from the CCA just after the retrieval remained a concern. In case 2, a 79-year-old female with acute right CCA occlusion underwent retrograde thrombectomy in the same manner. Because manual retrieval failed, a Fogarty balloon catheter inserted from the arteriotomy successfully retrieved the entire thrombus with minimal blood loss.

LESSONS

Retrograde thrombectomy through the arteriotomy of the cervical carotid bifurcation safely and effectively recanalizes acute embolic occlusion of the CCA alone.

Open access

Sternocleidomastoid muscle-splitting method for high cervical carotid endarterectomy: illustrative cases

Atsushi Sato, Tetsuo Sasaki, Toshihiro Ogiwara, Kazuhiro Hongo, and Tetsuyoshi Horiuchi

BACKGROUND

The number of cervical carotid endarterectomies (CEAs) has decreased as carotid artery stenting (CAS) has increased. However, CEA and CAS both have advantages and disadvantages; therefore, appropriate procedures must be selected for individual patients. High-positioned carotid artery stenosis presents technical challenges for CEA and is occasionally managed by performing CAS. However, CAS is associated with a high risk of thrombosis in patients with soft plaques, suggesting a clinical need for a better procedure. Consequently, appropriate surgical treatment for patients requiring high-level CEAs is essential.

OBSERVATIONS

In this study, a novel and straightforward method was devised. The primary concept underlying this technique is separation of the sternocleidomastoid muscle (SCM) from other anatomical structures to ensure a wider surgical field. By anatomically separating the SCM into the sternal and clavicular head groups, the objective of the wider surgical field can be met. Herein, we report technical innovations in high-positioned carotid artery stenosis and evaluate their efficacy in two patients.

LESSONS

In conclusion, high CEA surgery using this new method is valuable and may eliminate barriers to more advanced approaches.

Open access

Spinal arteriovenous malformation with a calcified nodule: illustrative case

Ping-Chuan Liu, Chung-Chia Huang, and Ching-Lin Chen

BACKGROUND

This article describes a rare case of cervical spinal arteriovenous malformation (AVM) mimicking a neurogenic spinal tumor.

OBSERVATIONS

A 22-year-old female presenting with a C6–7 AVM with a calcification nodule experienced new-onset acute right upper radiculopathy associated with extradural compression of the spinal cord. Note that spinal AVMs with a calcified nodule are rare. Endovascular embolization is generally used to relieve the symptoms of AVM; however, this procedure cannot relieve cord compression, particularly in cases complicated by calcified nodules. This article discusses treatment options.

LESSONS

Decompression surgery is preferable to endovascular embolization because it alleviates symptoms while preventing cord compression and minimizing the risk of recurrence.

Open access

Radiation-induced cavernous malformations in the spine: patient series

Stefan W. Koester, Lea Scherschinski, Visish M. Srinivasan, Katherine Karahalios, Kavelin Rumalla, Dimitri Benner, Joshua S. Catapano, Robert F. Spetzler, and Michael T. Lawton

BACKGROUND

Radiation-induced spinal cord cavernous malformations (RISCCMs) are a rare subset of central nervous system lesions and are more clinically aggressive than congenital cavernous malformations (CMs). The authors assessed the characteristics and outcomes of patients with RISCCM at a single institution and systematically reviewed the pertinent literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

OBSERVATIONS

Among the 146 spinal CMs at the authors’ institution, 3 RISCCMs were found. Symptom duration ranged from 0.1 to 8.5 months (mean [standard deviation], 3.2 [4.6] months), and latency ranged from 16 to 29 years (22.4 [9.6] years). All 3 RISCCMs were surgically treated with complete resection; 2 patients had stable outcomes, and 1 improved postoperatively. A review of 1240 articles revealed 20 patients with RISCCMs. Six of these patients were treated with resection, 13 were treated conservatively, and in 1 case, the treatment type was not stated. Five of the 6 patients treated surgically reported improvement postoperatively or at follow-up; 1 was stable, and none reported worsened outcomes.

LESSONS

RISCCMs are rare sequelae following radiation that inadvertently affect the spinal cord. Altogether, the frequency of stable and improved outcomes on follow-up suggests that resection could prevent further patient decline caused by symptoms of RISCCM. Therefore, surgical management should be considered primary therapy in patients presenting with RISCCMs.

Open access

Vessel wall imaging and carotid artery stenting for recurrent cervical internal carotid artery vasospasm syndrome: illustrative case

Shinya Tokunaga, Yukihiro Yamao, Takakuni Maki, Akira Ishii, Tomoaki Miyake, Ken Yasuda, Yu Abekura, Masakazu Okawa, Takayuki Kikuchi, Yasutaka Fushimi, Kazumichi Yoshida, and Susumu Miyamoto

BACKGROUND

Recurrent cervical internal carotid artery vasospasm syndrome (RCICVS) causes cerebral infarction, ocular symptoms, and occasionally chest pain accompanied by coronary artery vasospasm. The etiology and optimal treatment remain unclear.

OBSERVATIONS

The authors report a patient with drug-resistant RCICVS who underwent carotid artery stenting (CAS). Magnetic resonance angiography revealed recurrent vasospasm in the cervical segment of the internal carotid artery (ICA). Vessel wall imaging during an ischemic attack revealed vascular wall thickening of the ICA, similar to that in reversible cerebral vasoconstriction syndrome. The superior cervical ganglion was identified at the anteromedial side of the stenosis site. Coronary artery stenosis was also detected. After CAS, the symptoms of cerebral ischemia were prevented for 2 years, but bilateral ocular and chest symptoms did occur.

LESSONS

Vessel wall imaging findings suggest that RCICVS is a sympathetic nervous system-related disease. CAS could be an effective treatment for drug-resistant RCICVS to prevent cerebral ischemic events.

Open access

Etiology of spastic foot drop among 16 patients undergoing electrodiagnostic studies: patient series

Lisa B. E. Shields, Vasudeva G. Iyer, Yi Ping Zhang, and Christopher B. Shields

BACKGROUND

Differentiating foot drop due to upper motor neuron (UMN) lesions from that due to lower motor neuron lesions is crucial to avoid unnecessary surgery or surgery at the wrong location. Electrodiagnostic (EDX) studies are useful in evaluating patients with spastic foot drop (SFD).

OBSERVATIONS

Among 16 patients with SFD, the cause was cervical myelopathy in 5 patients (31%), cerebrovascular accident in 3 (18%), hereditary spastic paraplegia in 2 (12%), multiple sclerosis in 2 (12%), chronic cerebral small vessel disease in 2 (12%), intracranial meningioma in 1 (6%), and diffuse brain injury in 1 (6%). Twelve patients (75%) had weakness of a single leg, whereas 2 others (12%) had bilateral weakness. Eleven patients (69%) had difficulty walking. The deep tendon reflexes of the legs were hyperactive in 15 patients (94%), with an extensor plantar response in 9 patients (56%). Twelve patients (75%) had normal motor and sensory conduction, 11 of whom had no denervation changes of the legs.

LESSONS

This study is intended to raise awareness among surgeons about the clinical features of SFD. EDX studies are valuable in ruling out peripheral causes of foot drop, which encourages diagnostic investigation into a UMN source for the foot drop.

Open access

Cervical radiculopathy due to extracranial vertebral artery dissection treated by stent placement with a flow diversion effect: illustrative case

Hiroaki Matsumoto, Ikuya Yamaura, Atsushi Matsumoto, Shiro Miyata, Yusuke Tomogane, Hiroaki Minami, Atsushi Masuda, and Yasuhisa Yoshida

BACKGROUND

Cervical radiculopathy due to extracranial vertebral artery dissection (VAD) is extremely rare. The disease is usually treated with conservative treatment because of its favorable prognosis. However, there is a possibility that conservative treatment may bring about no improvement in radiculopathy. Although stent placement with a flow diversion effect may be effective in such cases, there are no reported cases that were treated with stent placement.

OBSERVATIONS

A 40-year-old healthy man presented with severe right neck pain, right arm pain, and right arm weakness after cracking his neck. A neurological examination revealed right C5 radiculopathy. Neuroimaging studies revealed right extracranial VAD. The VAD compressed the right C5 nerve root. Although medications were administered, there was no improvement in the symptoms. He experienced severe radicular pain. The authors performed stent placement with a flow diversion effect 10 days after the onset of VAD. His radicular pain improved immediately after the procedure, and the remaining radiculopathy completely improved within 1 month. Follow-up angiography showed complete improvement of the VAD.

LESSONS

Stent placement with a flow diversion effect may be considered when radiculopathy that hinders a patient’s daily life exists. Stent placement may bring about rapid improvement in radiculopathy, especially radicular pain.

Open access

Bow hunter’s syndrome: temporary obstruction of blood flow in the affected vertebral artery during posterior occipitocervical fusion. Illustrative case

Takeru Yokota, Koji Otani, Junichi Handa, Takuya Nikaido, Takao Kojima, Naoki Sato, and Shinichi Konno

BACKGROUND

Bow hunter’s syndrome (BHS) is a rare condition characterized by mechanical impingement of a vertebral artery (VA) during neck rotation followed by vertebrobasilar insufficiency. Posterior fusion is a typical surgical method for BHS.

OBSERVATIONS

The case of a 70-year-old Japanese man who presented with presyncope that occurred during right cervical rotation is reported. Given the possibility of vertebrobasilar insufficiency, digital subtraction angiography and computed tomography angiography were performed and showed a hypoplastic right VA and severe stenosis of the left VA over the occiput (O)–C2 level. The blood flow of the left VA was interrupted by right cervical rotation, with resumption of blood flow on left cervical rotation. BHS was diagnosed, and posterior fusion at the O–C2 level was performed. Immediately after implant fixation, selective arteriography confirmed disruption of blood flow in the left VA. The rods were removed immediately; resumption of blood flow was confirmed; and the rods were refixed, anatomically bent with slight left cervical rotation. Then, sustained blood flow in the left VA was confirmed.

LESSONS

Posterior fixation for BHS can induce VA occlusion due to minor changes in cervical spine alignment. Intraoperative selective arteriography is a necessary tool to identify occlusion of the affected VA.

Open access

Tentorial dural arteriovenous fistula with perimedullary venous drainage–associated cervical myelopathy: illustrative case

Sergi Cobos Codina, Luis Miguel Bernal García, José Antonio Rodríguez Sánchez, Tania Gavilán Iglesias, and Luis Fernández de Alarcón

BACKGROUND

Tentorial dural arteriovenous fistulas (DAVFs) with perimedullary venous drainage causing cervical myelopathy are very uncommon conditions with an extremely aggressive behavior. When the characteristic radiological clues are missing, the unspecific clinical picture may cause delay and make the diagnosis challenging.

OBSERVATIONS

Here the authors report a case of a 58-year-old man who developed progressive spastic tetraparesis and dyspnea with an extensive mild enhancing cervical cord lesion initially oriented as a neurosyphilis-associated transverse myelitis. Acute worsening after steroid administration redirected the diagnosis, and a tentorial Cognard type V DAVF was elicited. The microsurgical disconnection process is described, and previously documented cases in the literature are reviewed.

LESSONS

If a DAVF is highly suspected, it is important to consider the possibility of its intracranial origin, and spinal as well as cerebral arteriography must be performed.