Surgical clip occlusion of the V3 segment to prevent recurrent cerebral infarction associated with extracranial vertebral artery dissection: A case report
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Ryo Aiura, Masaki Matsumoto, Tohru Mizutani, Tatsuya Sugiyama, Daisuke TaniokaArticle Type:
- Department of Neurosurgery, Showa University Hospital, Tokyo, Shinagawa-ku, Japan.
Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ryo Aiura, Masaki Matsumoto, Tohru Mizutani, Tatsuya Sugiyama, Daisuke Tanioka. Surgical clip occlusion of the V3 segment to prevent recurrent cerebral infarction associated with extracranial vertebral artery dissection: A case report. 15-Oct-2020;11:337
How to cite this URL: Ryo Aiura, Masaki Matsumoto, Tohru Mizutani, Tatsuya Sugiyama, Daisuke Tanioka. Surgical clip occlusion of the V3 segment to prevent recurrent cerebral infarction associated with extracranial vertebral artery dissection: A case report. 15-Oct-2020;11:337. Available from: https://surgicalneurologyint.com/surgicalint-articles/10324/
Abstract
Background: Recurrent cerebral infarction caused by traumatic extracranial vertebral artery dissection (EVAD) is treated medically and surgically. We report a case of EVAD that was treated using surgical clip occlusion of the V3 segment to prevent recurrent cerebral infarction.Case Description: A 48-year-old man was admitted for a cerebral infarction caused by EVAD and was treated using 200 mg/day cilostazol. Afterward, the cerebral infarction recurred. Digital subtraction angiography revealed that initial severe stenosis of the VA ostium resulted in the final occlusion and that collateral vessels to the VA remained. We continued antiplatelet therapy, but the cerebral infarction recurred due to thromboembolism of the collateral vessels. Parent artery occlusion was planned. We exposed the V3 segment of the VA and clipped it to prevent the recurrence of cerebral infarction.
Conclusion: Surgical clip occlusion of the V3 segment was effective for treating recurrent cerebral infarction caused by traumatic EVAD that had remained an issue despite continuing medical therapy.
Keywords: Extracranial vertebral artery dissection, Occlusion clipping, Parent artery occlusion, V3 segment, Vertebral artery
INTRODUCTION
Traumatic extracranial vertebral artery dissection (EVAD) occurs less frequently than intracranial VA dissection but is recognized as an important cause of ischemic stroke. EVAD has occurred after spinal manoeuver[ 1 , 10 ] and has often caused thrombotic cerebral infarction.[ 1 ] Medical therapy is recommended as a first-line treatment for EVAD.[ 1 , 3 , 6 ] Despite the continuation of medical therapy, if a recurrent ischemic stroke occurs, which often presents as transient ischemic attacks or aneurysms, surgical parent artery occlusion (PAO) is performed.[ 2 , 4 , 5 , 7 - 9 ] We report a rare case of traumatic EVAD with recurrent cerebral infarction. The patient was effectively treated with surgical clip occlusion of the V3 segment of VA and had no recurrence of cerebral infarction.CASE DESCRIPTION
A 48-year-old man without connective tissue disease received a neck massage 2 years before being admitted to our hospital. Two months after the massage, he experienced vertigo and underwent magnetic resonance imaging (MRI) at another hospital. MRI revealed bilateral cerebellar infarction; however, its cause could not be determined. One year later, he received another neck massage and experienced vertigo. He visited the same hospital, and a second MRI revealed left cerebellar infarction and poor flow to the left VA [ Figures 1a and b ]. Digital subtraction angiography (DSA) revealed dissection from the VA ostium to the V2 segment and anastomoses between the VA and collateral vessels distal to the VA dissection [ Figure 1c ]. The neurosurgeon initiated antiplatelet therapy (200 mg/day cilostazol) to prevent cerebral infarction. One month later, the neurosurgeon consulted our hospital.Figure 1:
(a and b) Magnetic resonance images showing left cerebellar infarction and poor flow through the left vertebral artery. (c) Left subclavian artery angiography showing dissection from the vertebral artery ostium to the V2 segment, vertebral artery ostial stenosis (star), and collateral vessels (arrow).Figure 2:
(a) Magnetic resonance images showing left occipital lobe infarction. (b and c) Left subclavian artery angiography showing vertebral artery flow from the collateral vessels (arrowhead), antegrade vertebral artery slow flow (arrow) from the vertebral artery ostium, and vertebral artery ostial occlusion (star).Figure 3:
(a and b) Magnetic resonance images showing left cerebellar infarction and right occipital lobe infarction. (c) Left subclavian artery angiography showing antegrade vertebral artery slow flow from the collateral vessels. (d) Right vertebral artery angiography showing the dominant right vertebral artery.There was no requirement for IRB/ethics committee approval. The patient provided consent for the publication of this case report.
DISCUSSION
Several studies reported traumatic EVAD occurrence postspinal manoeuvers, including chiropractic manipulation and neck rotation.[ 1 , 10 ] These manoeuvers cause neurological sequelae resulting from cerebral ischemia. The cause of cerebral ischemia can be thromboembolism, hypoperfusion, or a combination of both. However, thromboembolism is considered the major cause of ischemic symptoms.[ 1 ] Antiplatelet or anticoagulant therapy is the recommended treatment for thromboembolism.[ 1 , 3 , 6 ] Surgical treatment is suggested for patients with traumatic EVAD accompanied by recurrent cerebral ischemia despite medical therapy.[ 5 , 7 ] Endovascular or direct surgery is selected on an individual basis.Seven cases of traumatic EVAD treated with PAO were reported [ Table 1 ].[ 2 , 4 , 5 , 7 - 9 ] Most cases occurred in younger patients, on the right side and on the V2 segment of the VA dissection. However, our case was the only one in which the cerebral infarction recurred after medical therapy. Endovascular and direct surgery was performed in three[ 4 , 7 , 9 ] and five[ 2 , 5 , 8 ] cases, respectively. Cohen et al.[ 4 ] reported an involved coil embolization of the right VA. A stent was used to treat the left VA due to bilateral EVAD. Two other cases were treated using coil embolization of the affected VA because the unaffected VA remained intact.[ 7 , 9 ] In all three cases, VA dissection was limited to the V2 segment and was approached from the VA ostium.
For direct surgery, multiple studies have reported PAO with bypass,[ 2 , 5 , 8 ] but our case was the first, in which surgical clip occlusion was executed without bypass because the unaffected VA was intact. According to Morgan and Sekhon,[ 8 ] the reason that direct surgery was selected was that the dissection ranged from the VA ostium to the V2 segment. Direct surgery is generally the most effective treatment for
Our patient experienced cerebral infarction despite VA ostial occlusion. We expected that the thrombus was formed due to a collision that occurred between the flow of several collateral vessels at the VA. Therefore, we decided to clip the V3 segment, which was more distally positioned than the collateral vessels [ Figure 6 ]. To treat VA ostial occlusion using endovascular surgery, we were required to approach the occlusion from the unaffected VA through the intracranial VA union. No cases of surgical clip occlusion to prevent cerebral infarction for EVAD have been reported, and our surgery represents a treatment option that may be ideal for other patients, depending on the precise situations in which cerebral infarction or dissection occurs.
Figure 6:
(a) Severe vertebral artery ostial stenosis, antegrade vertebral artery flow, and retrograde flow from collateral vessels collided and produced thromboembolism. (b) Vertebral artery ostial occlusion and collision of flow from several collateral vessels resulted in thromboembolism. (c) After surgical clip occlusion.CONCLUSION
Surgical PAO is selected when patients experience recurrent ischemic strokes despite continuous medical therapy. Surgical occlusion using only clips without intracranial operation and craniotomy is a treatment option if the patient’s pathology permits.Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.Financial support and sponsorship
Nil.Conflicts of interest
There are no conflicts of interest.References
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