Microvascular decompression of a C-2 segmental-type vertebral artery producing trigeminal hypesthesia

Case report

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The authors report a case of trigeminal hypesthesia caused by compression of the spinal cord by a C-2 segmental-type vertebral artery (VA) that was successfully treated with microvascular decompression. Aberrant intradural VA loops have been reported as causes of cervical myelopathy, some of which improved with microvascular decompression. A 52-year-old man presented with progressive complaints of headache, dizziness, left facial numbness, and left upper-extremity paresthesia that worsened when turning his head to the right. Magnetic resonance imaging of the cervical spine showed the left VA passing intradurally between the axis and atlas, foregoing the C-1 foramen transversarium, and impinging on the spinal cord. The patient underwent left C-1 and C-2 hemilaminectomies followed by microvascular decompression of an aberrant VA loop compressing the spinal cord. The patient subsequently reported complete resolution of symptoms.

Abbreviation used in this paper:VA = vertebral artery.

Abstract

The authors report a case of trigeminal hypesthesia caused by compression of the spinal cord by a C-2 segmental-type vertebral artery (VA) that was successfully treated with microvascular decompression. Aberrant intradural VA loops have been reported as causes of cervical myelopathy, some of which improved with microvascular decompression. A 52-year-old man presented with progressive complaints of headache, dizziness, left facial numbness, and left upper-extremity paresthesia that worsened when turning his head to the right. Magnetic resonance imaging of the cervical spine showed the left VA passing intradurally between the axis and atlas, foregoing the C-1 foramen transversarium, and impinging on the spinal cord. The patient underwent left C-1 and C-2 hemilaminectomies followed by microvascular decompression of an aberrant VA loop compressing the spinal cord. The patient subsequently reported complete resolution of symptoms.

Tortuous extradural vertebral artery (VA) loops have been reported as causes of cervical radiculopathy, some of which have benefited from anterior or posterior cervical decompression.1,6,7,9,13,18,23,25 Similarly, tortuous intradural VA loops have been reported as causes of brainstem compression, some of which improved with microvascular decompression.10–12,17,19,20,29,30

Vertebral arteries with an aberrant, not tortuous, segment are more rare. Cervical myelopathy with or without radiculopathy resulting from anomalous VA anatomy has been described.3,8,21,22,24,26,27,31–34 We present a case of the successful surgical treatment of symptomatic high cervical cord compression caused by an aberrant VA segment. Interestingly, the predominant symptom of this high cervical cord compression was facial hypesthesia.

Case Report

History and Examination

A 52-year-old male police officer, formerly a Navy SEAL, with a medical history of hypertension and hyperlipidemia, presented with progressive complaints of headache, dizziness, left facial numbness, and left upper-extremity paresthesia that worsened when he turned his head to the right. Findings from previous evaluations for stroke, neoplasm, and benign positional vertigo had been negative. According to the report, MRI of the cervical spine showed cervical stenosis.

On examination, the patient was alert and fully oriented. Cranial nerves were intact, except for decreased sensation to touch in the left V1, V2, and V3 distributions. Motor strength was full throughout. Sensation was diminished diffusely to light touch and pin prick in the left upper extremity without discrete dermatomal distribution. Reflexes were normoactive without evidence of Hoffman, clonus, or Babinski signs. Magnetic resonance imaging of the cervical spine showed the left VA passing intradurally between the axis and atlas, foregoing the C-1 foramen transversarium, and impinging on the spinal cord (Fig. 1). Findings of a 4-vessel cerebral angiogram were negative for arteriovenous dural fistula or other vascular abnormalities but confirmed an aberrant course of the left VA, with premature entry intradurally between C-1 and C-2 (Fig. 2). Provocative movements and positioning of the head failed to demonstrate significant movement or kinking of the artery.

Fig. 1.
Fig. 1.

Left: Axial T2-weighted MR image of the cervical spine at the level of the C-2 vertebral body showing an aberrant left VA entering the spinal canal via the C1–2 foramen, passing intradurally, and abutting the spinal cord. Right: Sagittal T2-weighted MR image of the cervical spine showing the aberrant left VA segment, which has passed intradurally prematurely, wrapping around the spinal cord.

Fig. 2.
Fig. 2.

Lateral left vertebral injection cerebral arteriogram showing premature entry of the left VA via the left C1–2 foramen (arrow).

Operation

A conservative course emphasizing blood pressure control and analgesia was undertaken unsuccessfully. After discussing the risks and benefits, the patient was taken to surgery for a vascular decompression of the cervical spinal cord. The patient was placed prone, and left C-1 and C-2 hemilaminectomies were performed. Under the operative microscope, the dura was opened and the aberrant, pulsatile VA was found compressing the cervical cord (Fig. 3). A microvascular decompression was accomplished by displacing the VA and cushioning it using Teflon. This decompression was then complemented with an expansion duraplasty using a dural substitute. A watertight seal was confirmed with Valsalva maneuvers during inspection of the suture line under the microscope. Fat and dural sealant were used to supplement the repair (Video 1).

Fig. 3.
Fig. 3.

A: Dorsal intraoperative view of the operative field showing durotomy with accompanying tack-up sutures in the foreground and the aberrant left VA displacing dorsal nerve roots and compressing the spinal cord. B: Dorsal intraoperative view showing Teflon microvascular decompression of the lateral spinal cord. C: Dorsal intraoperative view showing expansion duraplasty.

Video 1. Intraoperative video showing durotomy, microvascular decompression, and expansion duraplasty. Copyright Edward A. M. Duckworth. Published with permission. Click here to view with Media Player. Click here to view with Quicktime.

Postoperative Course

On postoperative Day 1, the patient was neurologically intact and reported improved symptoms. On postoperative Day 3, with continued symptom improvement, he was discharged home without evidence of new neurological deficit or CSF leak. At the 2-week follow-up, the patient reported complete resolution of symptoms. Six months later, he was back at work as a police officer and otherwise doing well.

Discussion

Structural anomalies of the vertebrobasilar system can produce a variety of neurological symptoms. In cases of direct compression of neural structures by the vertebrobasilar system, local mass effect exacerbated by the pulsatile nature of arterial blood flow can produce cranial nerve or pontomedullary dysfunction, cervical myelopathy, or cervical radiculopathy. Tortuosity of the VA, in particular, has been shown to produce extradural cervical radiculopathy as well as intradural brainstem dysfunction by direct compression.1,6,7,9–13,17–20,23,25,29,30 Such tortuosity has been observed postmortem in anatomical studies, as well as in vivo on radiography, MRI, or via traditional angiography.2,5,28,35

Classically, Jannetta linked vascular compression of the trigeminal nerve to trigeminal neuralgia, and showed that microvascular decompression of the affected nerve could produce symptomatic relief.14–16 In these cases, trigeminal nerve dysfunction is secondary to compression by dolichoectatic or tortuous vessels of the posterior circulation. These tortuous vessels stray from natural anatomical corridors and cause direct compression of the trigeminal nerve. Other dolichoectatic vessels can similarly affect cranial nerves, not exclusively those of the vertebrobasilar system.4

In our case, the patient likely had trigeminal distribution hypesthesia secondary to compression of the caudal reaches of the spinal trigeminal nucleus. The spinal trigeminal nucleus spans the medulla and upper cervical cord, receiving deep/crude touch, pain, and temperature sensations from the ipsilateral face via general somatic afferent fibers. Afferent fibers to the spinal trigeminal nucleus travel principally via branches of the trigeminal nerve, but the facial, glossopharyngeal, and vagal nerves also contribute sensory modalities from parts of the mouth, ear, and meninges. Peripheral nerve fibers, most prominently those with neurons in the trigeminal ganglion, send central projections to the brainstem, entering via the pons or medulla. These projections descend to the medulla and upper cervical cord, forming the spinal trigeminal tract, synapsing with neurons in the adjacent spinal trigeminal nucleus. Second-order neuronal projections cross the midline and ascend in the contralateral brainstem as the trigeminothalamic tract to the contralateral ventral posterior medial thalamus. Third-order neurons in the thalamus then project to neurons in the sensory cortex of the postcentral gyrus. As opposed to the classic microvascular compression of first-order neurons seen in trigeminal neuralgia, our patient likely had symptoms due to vascular compression of the central projections of these first-order neurons, as well as of the second-order neurons themselves (Fig. 4).

Fig. 4.
Fig. 4.

Illustration demonstrating postulated compression of the spinal trigeminal tract (blue column) by a pulsatile, aberrant VA abutting the lateral spinal cord. Copyright Jovany Cruz Navarro. Published with permission.

Cervical myelopathy may be caused by VA tortuosity, which has been observed with an incidence of 2.7% in a cadaveric study, but can also result from arteries that follow an aberrant course.5 A review of 300 VA angiograms by Tokuda et al. found 7 cases of anomalous atlantoaxial portions of the VA.28 Of these anomalous angiograms, 2 were found to have VAs coursing into the spinal canal between C-1 and C-2, as was observed in our case; the term “C2 segmental type of the vertebral artery” was used to describe this anomaly. A review of the literature reveals 11 related cases, predominantly from Japan, of similar anomalies causing clinical symptoms. In these cases, the predominant symptoms were those of cervical myelopathy, caused by unilateral or bilateral premature intradural passage of the VA, or a fenestration of the VA, resulting in compression of the spinal cord.3,8,21,22,24,26,27,31–34 Interestingly, none of the patients in the aforementioned cases reported trigeminal distribution symptoms.

Such VA anomalies may be more often symptomatic due to the limited diameter of the upper cervical canal, which, though generous, is not as wide as the spinal canal at the foramen magnum and cannot accommodate an intruding vascular structure without cervical cord compression. In some of the reported cases, surgical intervention was undertaken. Most commonly, posterior cervical approaches with some combination of suboccipital craniectomy, cervical laminectomy, and expansion duraplasty were used. Vascular decompression was frequently used; however, an additional technique often described is VA transposition followed by tacking using suture or prostheses.26,27

While cervical myelopathy secondary to aberrant VA compression has been described, our case seems to be the first reported instance of trigeminal hypesthesia from vascular compression of the spinal trigeminal tract and nucleus.

Vertebral artery compression of the cervical spinal cord can produce symptoms of cervical myelopathy or cervicomedullary compression. Though the literature is sparse on the topic, several case reports have linked such compression to premature or aberrant intradural entry of the VA into the spinal canal. None of the previously reported cases, however, mention trigeminal distribution dysfunction as a predominant symptom. Surgical interventions have been undertaken with good effect. Our case supports the notion that surgical decompression of VA compression of the high cervical cord provides good outcomes, particularly in the relief of trigeminal hypesthesia. It remains unclear, however, which aspect of the surgical intervention—microvascular decompression with Teflon or cervical laminectomy with expansion duraplasty—resulted in symptomatic relief, if not both.

Acknowledgment

Illustration by Jovany C. Navarro.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Sellin. Acquisition of data: Duckworth, Al-Hafez. Analysis and interpretation of data: Sellin. Drafting the article: Sellin. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Duckworth. Study supervision: Duckworth, Sellin.

References

  • 1

    Anderson REShealy CN: Cervical pedicle erosion and rootlet compression caused by a tortuous vertebral artery. Radiology 96:5375381970

  • 2

    Babin EHaller M: Correlation between bony radiological signs and dolichoarterial loops of the cervical vertebral artery. Neuroradiology 7:15171974

  • 3

    Ball BGKrueger BRPiepgras DG: Anomalous vertebral artery compression of the spinal cord at the cervicomedullary junction. Surg Neurol Int 2:1032011

  • 4

    Colapinto EVCabeen MAJohnson LN: Optic nerve compression by a dolichoectatic internal carotid artery: case report. Neurosurgery 39:6046061996

  • 5

    Curylo LJMason HCBohlman HHYoo JU: Tortuous course of the vertebral artery and anterior cervical decompression: a cadaveric and clinical case study. Spine (Phila Pa 1976) 25:286028642000

  • 6

    Detwiler PWPorter RWHarrington TRSonntag VKHSpetzler RF: Vascular decompression of a vertebral artery loop producing cervical radiculopathy. Case report. J Neurosurg 89:4854881998

  • 7

    Duthel RTudor CMotuo-Fotso MJBrunon J: Cervical root compression by a loop of the vertebral artery: case report. Neurosurgery 35:1401421994

  • 8

    Furumoto TNagase JTakahashi KItabashi TIai HIshige N: Cervical myelopathy caused by the anomalous vertebral artery. A case report. Spine (Phila Pa 1976) 21:228022831996

  • 9

    Hage ZAAmin-Hanjani SWen DCharbel FT: Surgical management of cervical radiculopathy caused by redundant vertebral artery loop. Case report. J Neurosurg Spine 17:3373412012

  • 10

    Himi TKataura ATokuda SSumi YKamiyama KShitamichi M: Downbeat nystagmus with compression of the medulla oblongata by the dolichoectatic vertebral arteries. Am J Otol 16:3773811995

  • 11

    Hongo KKobayashi SHokama MSugita K: Vertebral artery section for treating arterial compression of the medulla oblongata. Case report. J Neurosurg 79:1161181993

  • 12

    Hongo KNakagawa HMorota NIsobe M: Vascular compression of the medulla oblongata by the vertebral artery: report of two cases. Neurosurgery 45:9079101999

  • 13

    Horgan MAHsu FPFrank EH: Cervical radiculopathy secondary to a tortuous vertebral artery. Case illustration. J Neurosurg 89:4891998

  • 14

    Jannetta PJ: Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 26:1 Part 21591621967

  • 15

    Jannetta PJ: Neurovascular compression in cranial nerve and systemic disease. Ann Surg 192:5185251980

  • 16

    Jannetta PJTrigeminal neuralgia: treatment by microvascular decompression. Wilkins RHRengachary SS: Neurosurgery New YorkMcGraw-Hill1996. 3:39613968

  • 17

    Kim PIshijima BTakahashi HShimizu HYokochi M: Hemiparesis caused by vertebral artery compression of the medulla oblongata. Case report. J Neurosurg 62:4254291985

  • 18

    Korinth MCMull M: Vertebral artery loop causing cervical radiculopathy. Surg Neurol 67:1721732007

  • 19

    Koyama S: Lower medulla and upper cervical cord compression caused by bilateral vertebral artery. Case illustration. J Neurosurg 94:2 Suppl3372001

  • 20

    Koyama SMaeda TKomine A: [Medulla and upper cervical cord compression by bilateral vertebral artery presented with myelopathy and drop attack: case report.]. No To Shinkei 54:4354392002. (Jpn)

  • 21

    Morikawa KOhkawa NYamashita S: [Surgical decompression for the C-1 and C-2 sensory roots and upper cervical cord in a case with cervical myelopathy and occipital neuralgia due to bilateral fenestration of vertebral artery: a case report.]. No Shinkei Geka 21:103510381993. (Jpn)

  • 22

    Nishiura TFujiwara KHanda AGotoh MTsuno KIshimitsu H: [Cervical myelopathy caused by bilateral vertebral artery compression.]. No Shinkei Geka 26:45501998. (Jpn)

  • 23

    Sakaida HOkada MYamamoto A: Vascular reconstruction of a vertebral artery loop causing cervical radiculopathy and vertebrobasilar insufficiency. Case report. J Neurosurg 94:1 Suppl1451492001

  • 24

    Satoh SYamamoto NKitagawa YUmemori TSasaki TIida T: Cervical cord compression by the anomalous vertebral artery presenting with neuralgic pain. Case report. J Neurosurg 79:2832851993

  • 25

    Sharma RRParekh HCPrabhu SGurusinghe NTBertolis G: Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:6696721993

  • 26

    Takahashi YSugita SUchikado HMiyagi TTokutomi TShigemori M: Cervical myelopathy due to compression by bilateral vertebral arteries—case report. Neurol Med Chir (Tokyo) 41:3223242001

  • 27

    Takei HSagae MChiba KOgino T: The long-term follow-up of surgical treatment for cervical myelopathy with severe nape and upper arm pain caused by the anomalous vertebral artery: case report. Spine (Phila Pa 1976) 33:E611E6132008

  • 28

    Tokuda KMiyasaka KAbe HAbe STakei HSugimoto S: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:4104131985

  • 29

    Tomasello FAlafaci CSalpietro FMLongo M: Bulbar compression by an ectatic vertebral artery: a novel neurovascular construct relieved by microsurgical decompression. Neurosurgery 56:1 Suppl1171242005

  • 30

    Ubogu EEChase CMVerrees MAMetzger AKZaidat OO: Cervicomedullary junction compression caused by vertebral artery dolichoectasia and requiring surgical treatment. Case report. J Neurosurg 96:1401432002

  • 31

    Vincentelli FCaruso GRabehanta PBRey M: Surgical treatment of a rare congenital anomaly of the vertebral artery: case report and review of the literature. Neurosurgery 28:4164201991

  • 32

    Watanabe KHasegawa KTakano K: Anomalous vertebral artery-induced cervical cord compression causing severe nape pain. Case report. J Neurosurg 95:1 Suppl1461492001

  • 33

    Yano KMurase SKuroda TNoguchi KTanabe YYamada H: Cervical cord compression by the vertebral artery causing a severe cervical pain: case report. Surg Neurol 40:43461993

  • 34

    Yousry TASeelos KWidenka DCSteiger HJ: Vertebral artery loop causing cervical compression. AJNR Am J Neuroradiol 17:180018011996

  • 35

    Zimmerman HBFarrell WJ: Cervical vertebral erosion caused by vertebral artery tortuosity. Am J Roentgenol Radium Ther Nucl Med 108:7677701970

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Edward A. M. Duckworth, M.D., M.S., Department of Neurosurgery, 1709 Dryden Rd., Ste. 750, Houston, TX 77030. email: edward.duckworth@bcm.edu.

Please include this information when citing this paper: published online June 27, 2014; DOI: 10.3171/2014.5.JNS131825.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Left: Axial T2-weighted MR image of the cervical spine at the level of the C-2 vertebral body showing an aberrant left VA entering the spinal canal via the C1–2 foramen, passing intradurally, and abutting the spinal cord. Right: Sagittal T2-weighted MR image of the cervical spine showing the aberrant left VA segment, which has passed intradurally prematurely, wrapping around the spinal cord.

  • View in gallery

    Lateral left vertebral injection cerebral arteriogram showing premature entry of the left VA via the left C1–2 foramen (arrow).

  • View in gallery

    A: Dorsal intraoperative view of the operative field showing durotomy with accompanying tack-up sutures in the foreground and the aberrant left VA displacing dorsal nerve roots and compressing the spinal cord. B: Dorsal intraoperative view showing Teflon microvascular decompression of the lateral spinal cord. C: Dorsal intraoperative view showing expansion duraplasty.

  • View in gallery

    Illustration demonstrating postulated compression of the spinal trigeminal tract (blue column) by a pulsatile, aberrant VA abutting the lateral spinal cord. Copyright Jovany Cruz Navarro. Published with permission.

References

1

Anderson REShealy CN: Cervical pedicle erosion and rootlet compression caused by a tortuous vertebral artery. Radiology 96:5375381970

2

Babin EHaller M: Correlation between bony radiological signs and dolichoarterial loops of the cervical vertebral artery. Neuroradiology 7:15171974

3

Ball BGKrueger BRPiepgras DG: Anomalous vertebral artery compression of the spinal cord at the cervicomedullary junction. Surg Neurol Int 2:1032011

4

Colapinto EVCabeen MAJohnson LN: Optic nerve compression by a dolichoectatic internal carotid artery: case report. Neurosurgery 39:6046061996

5

Curylo LJMason HCBohlman HHYoo JU: Tortuous course of the vertebral artery and anterior cervical decompression: a cadaveric and clinical case study. Spine (Phila Pa 1976) 25:286028642000

6

Detwiler PWPorter RWHarrington TRSonntag VKHSpetzler RF: Vascular decompression of a vertebral artery loop producing cervical radiculopathy. Case report. J Neurosurg 89:4854881998

7

Duthel RTudor CMotuo-Fotso MJBrunon J: Cervical root compression by a loop of the vertebral artery: case report. Neurosurgery 35:1401421994

8

Furumoto TNagase JTakahashi KItabashi TIai HIshige N: Cervical myelopathy caused by the anomalous vertebral artery. A case report. Spine (Phila Pa 1976) 21:228022831996

9

Hage ZAAmin-Hanjani SWen DCharbel FT: Surgical management of cervical radiculopathy caused by redundant vertebral artery loop. Case report. J Neurosurg Spine 17:3373412012

10

Himi TKataura ATokuda SSumi YKamiyama KShitamichi M: Downbeat nystagmus with compression of the medulla oblongata by the dolichoectatic vertebral arteries. Am J Otol 16:3773811995

11

Hongo KKobayashi SHokama MSugita K: Vertebral artery section for treating arterial compression of the medulla oblongata. Case report. J Neurosurg 79:1161181993

12

Hongo KNakagawa HMorota NIsobe M: Vascular compression of the medulla oblongata by the vertebral artery: report of two cases. Neurosurgery 45:9079101999

13

Horgan MAHsu FPFrank EH: Cervical radiculopathy secondary to a tortuous vertebral artery. Case illustration. J Neurosurg 89:4891998

14

Jannetta PJ: Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 26:1 Part 21591621967

15

Jannetta PJ: Neurovascular compression in cranial nerve and systemic disease. Ann Surg 192:5185251980

16

Jannetta PJTrigeminal neuralgia: treatment by microvascular decompression. Wilkins RHRengachary SS: Neurosurgery New YorkMcGraw-Hill1996. 3:39613968

17

Kim PIshijima BTakahashi HShimizu HYokochi M: Hemiparesis caused by vertebral artery compression of the medulla oblongata. Case report. J Neurosurg 62:4254291985

18

Korinth MCMull M: Vertebral artery loop causing cervical radiculopathy. Surg Neurol 67:1721732007

19

Koyama S: Lower medulla and upper cervical cord compression caused by bilateral vertebral artery. Case illustration. J Neurosurg 94:2 Suppl3372001

20

Koyama SMaeda TKomine A: [Medulla and upper cervical cord compression by bilateral vertebral artery presented with myelopathy and drop attack: case report.]. No To Shinkei 54:4354392002. (Jpn)

21

Morikawa KOhkawa NYamashita S: [Surgical decompression for the C-1 and C-2 sensory roots and upper cervical cord in a case with cervical myelopathy and occipital neuralgia due to bilateral fenestration of vertebral artery: a case report.]. No Shinkei Geka 21:103510381993. (Jpn)

22

Nishiura TFujiwara KHanda AGotoh MTsuno KIshimitsu H: [Cervical myelopathy caused by bilateral vertebral artery compression.]. No Shinkei Geka 26:45501998. (Jpn)

23

Sakaida HOkada MYamamoto A: Vascular reconstruction of a vertebral artery loop causing cervical radiculopathy and vertebrobasilar insufficiency. Case report. J Neurosurg 94:1 Suppl1451492001

24

Satoh SYamamoto NKitagawa YUmemori TSasaki TIida T: Cervical cord compression by the anomalous vertebral artery presenting with neuralgic pain. Case report. J Neurosurg 79:2832851993

25

Sharma RRParekh HCPrabhu SGurusinghe NTBertolis G: Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:6696721993

26

Takahashi YSugita SUchikado HMiyagi TTokutomi TShigemori M: Cervical myelopathy due to compression by bilateral vertebral arteries—case report. Neurol Med Chir (Tokyo) 41:3223242001

27

Takei HSagae MChiba KOgino T: The long-term follow-up of surgical treatment for cervical myelopathy with severe nape and upper arm pain caused by the anomalous vertebral artery: case report. Spine (Phila Pa 1976) 33:E611E6132008

28

Tokuda KMiyasaka KAbe HAbe STakei HSugimoto S: Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:4104131985

29

Tomasello FAlafaci CSalpietro FMLongo M: Bulbar compression by an ectatic vertebral artery: a novel neurovascular construct relieved by microsurgical decompression. Neurosurgery 56:1 Suppl1171242005

30

Ubogu EEChase CMVerrees MAMetzger AKZaidat OO: Cervicomedullary junction compression caused by vertebral artery dolichoectasia and requiring surgical treatment. Case report. J Neurosurg 96:1401432002

31

Vincentelli FCaruso GRabehanta PBRey M: Surgical treatment of a rare congenital anomaly of the vertebral artery: case report and review of the literature. Neurosurgery 28:4164201991

32

Watanabe KHasegawa KTakano K: Anomalous vertebral artery-induced cervical cord compression causing severe nape pain. Case report. J Neurosurg 95:1 Suppl1461492001

33

Yano KMurase SKuroda TNoguchi KTanabe YYamada H: Cervical cord compression by the vertebral artery causing a severe cervical pain: case report. Surg Neurol 40:43461993

34

Yousry TASeelos KWidenka DCSteiger HJ: Vertebral artery loop causing cervical compression. AJNR Am J Neuroradiol 17:180018011996

35

Zimmerman HBFarrell WJ: Cervical vertebral erosion caused by vertebral artery tortuosity. Am J Roentgenol Radium Ther Nucl Med 108:7677701970

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