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Vertebral Artery Aneurysm

Aneurysm of Vertebral Artery

A vertebral artery aneurysm is a rare occurrence in clinical practice and commonly develops after penetrating trauma that disrupts the anatomy of this blood vessel. Risk factors that are infrequently present are hypertension and coronary heart disease. Headaches and altered consciousness are the most common symptoms. The diagnosis is made through imaging studies, such as computed tomography and digital subtraction angiography, but magnetic resonance angiography is considered to be the optimal procedure for evaluating the lesion.


Presentation

Vertebral artery aneurysms (VAA) primarily develop at the junction of this vessel and the posterior inferior cerebellar artery (PICA) and are responsible for approximately 0.5-3% of all intracranial aneurysms reported in the literature [1]. Penetrating trauma, such as gunshot or stab wounds, is by far the most important cause of VAA, whereas blunt force trauma, atherosclerosis, fractures of the vertebral column, rheumatoid arthritis (RA), and syphilis are described as other potential etiologies [2]. Aneurysms of this vessel might rupture and induce subarachnoid hemorrhage (SAH) or cause infarction on the grounds of ischemia and thromboembolism [3], but VAAs can arise from previous dissection as well [4] [5] [6] [7]. The clinical presentation is comprised of two major symptoms - headache and an altered consciousness, ranging from mild changes to severe coma [3]. Other notable signs that are described in patients who suffered from a vertebral artery aneurysm are vertigo, vomiting, nausea, and Wallenberg syndrome (also known as lateral medullary syndrome) [3] [5]. Some authors report that a pulsating mass may be a feature of a VAA, often accompanied by bruits and thrills that are aggravated when the carotid artery is compressed [5].

Vascular Disease
  • Here we report the successful reconstruction of an asymptomatic extracranial left VA aneurysm, highlighting the treatment for extracranial VA aneurysm and showing the superiority of a hybrid operating room in cerebral vascular diseases.[ncbi.nlm.nih.gov]
  • diseases I73.0 Raynaud's syndrome I73.00 …… without gangrene I73.1 Thromboangiitis obliterans [Buerger's disease] I73.8 Other specified peripheral vascular diseases I73.89 Other specified peripheral vascular diseases Reimbursement claims with a date[icd10data.com]
  • disease registry Mean, 8.5 mo Drug-eluting balloon-expandable stents used in 56.8%, with BMS in 38.5% and self-expanding stents in 4.7% Change in mean stenosis (pre- to poststenting): 80.5%-5.3% 1 stroke occurred in 30-d periprocedural period Over 3-[bcidaho.com]
Torticollis
  • Torticollis is a symptom that can be related to different pathological mechanisms ranging from simple to life-threatening conditions. We report a child with recurrent torticollis caused by an intracranial dissecting vertebral artery aneurysm.[ncbi.nlm.nih.gov]
Pulsatile Tinnitus
  • In the US Registry, the most common presenting signs or symptoms are hypertension, headache, pulsatile tinnitus (swooshing or whooshing sound in the ears) and dizziness.[strokeassociation.org]
Vertigo
  • A 54-year-old man presented with neck pain, vertigo and loss of balance.[ncbi.nlm.nih.gov]
  • For these 88 patients in the vertigo group, there were no other pathologies that would lead to vertigo; hence the authors concluded that such vascular variations could be related to vertigo and dizziness [ 2 ].[pulsus.com]
  • Other notable signs that are described in patients who suffered from a vertebral artery aneurysm are vertigo, vomiting, nausea, and Wallenberg syndrome (also known as lateral medullary syndrome).[symptoma.com]
  • Patients may present late with hemi-sensory or motor deficit, dizziness, syncope, vertigo, tinnitus, peri-oral numbness, gait ataxia, dysarthria. deathess, poor memory, diplopia and occipital or neck ache 6 .[jpma.org.pk]
Dizziness
  • In both types a variety of other unpleasant physical feelings is common, such as dizziness, tension headaches, and feelings... ‎[books.google.com]
  • Congenital morphological abnormalities of the distal vertebral arteries (CMADVA) and their relationship with vertigo and dizziness. Med Sci Monit. 2004; 10: CR316–323. Foutrakis GN, Yonas H, Sclabassi RJ.[pulsus.com]
  • Patients may present late with hemi-sensory or motor deficit, dizziness, syncope, vertigo, tinnitus, peri-oral numbness, gait ataxia, dysarthria. deathess, poor memory, diplopia and occipital or neck ache 6 .[jpma.org.pk]
  • This may produce relative cerebral ischemia with neurologic symptoms such as dizziness, blurring of vision, headache, staggering, and occasionally olfactory hallucinations.[jamanetwork.com]
  • It began with some dizziness which I thought was not entirely abnormal, I thought perhaps I was overexerting myself. I skated off the ice to the bench. The dizziness became more severe and my vision started to blur.[vertebralarterydissection.com]
Nystagmus
  • Neurological examination revealed nystagmus and decreased sensation on the right-side of the face.[clinicalimagingscience.org]
  • […] syndrome: Contralateral weakness or paralysis (pyramidal tract) Contralateral numbness (medial lemniscus) Depending upon which areas of the brainstem or cerebellum are experiencing ischemia, the following signs may be present: Limb or truncal ataxia Nystagmus[emedicine.medscape.com]
  • CNS: Nystagmus, drowsiness, ataxia, dizziness, mental confusion, tremors, insomnia, headache, seizures. CV: Bradycardia, hypotension, cardiovascular collapse, ventricular fibrillation, conjunctivitis, diplopia, blurred vision.[slideshare.net]
Dysphasia
  • The patient was discharged with slight hoarseness and dysphasia 5 weeks after surgery. She had only slight hoarseness at 6 months. This complication was probably due to a neural toxic response to the Biobond.[ncbi.nlm.nih.gov]
  • Though the PICA showed good compensatory circulation, the patient experienced transient mild hoarseness and dysphasia that alter completely resolved [ 44 ]. Iihara et al. reported two cases of VDA involving the PICA in 2002.[medsci.org]
Dysmetria
  • The patient was a 10-year-old boy with a 4-year history of left recurrent torticollis, followed by hemiparesis, dysarthria, dysmetria, and tremor.[ncbi.nlm.nih.gov]

Workup

The diagnosis of a vertebral artery aneurysm must be made early on, which is why a thorough clinical and imaging workup is recommended as soon as suspicion toward this medical entity is raised. The physician should first obtain a detailed patient history that evaluates cardiovascular risk factors and the presence of other comorbidities. If penetrating trauma of the posterior cervical area is confirmed, employment of imaging studies is mandatory. Computed tomography (CT) and magnetic resonance imaging (MRI) must be initially performed to assess the surrounding tissues, but in order to make a definite diagnosis of a VAA, vascular-enhancing studies are necessary. CT angiography (CTA), with or without 3D reconstruction, MR angiography (contrast enhanced and 3D reconstruction) and digital subtraction angiography (DSA) have all been recommended in the assessment of the cranial circulation [4] [6]. Because of the limitations of CTA (overlapping with bony structures and time-consuming) and DSA (limited capacity to reveal atypical aneurysms), MR angiography is considered to be the gold standard [4] [6]. On these studies, radiologists frequently reveal the "pearl and string sign" - dilation of the vessel in a fusiform pattern with irregular narrowing of the lumen, whereas subarachnoid hemorrhage, thrombosis, or the formation of a vertebral-venous fistula can be observed as well [3] [4] [6].

Mediastinal Mass
  • Patient Data Age: 90 Gender: Male Large left mediastinal mass with stent and peripheral calcification. There is an aneurysm at the expected origin of the left vertebral artery.[radiopaedia.org]

Treatment

  • Vertebral artery aneurysms form a group of aneurysms having high rates of rebleeding, morbidity, and mortality, poor treatment outcomes, as well as low rate of surgical treatment.[ncbi.nlm.nih.gov]
  • Advances in endoscopic transnasal surgery have provided an additional approach for the treatment of these difficult lesions.[ncbi.nlm.nih.gov]
  • Combined endovascular stent and coil therapy is a promising technique for the treatment of wide-necked cerebral aneurysms.[ncbi.nlm.nih.gov]
  • This is a very rare condition in childhood, and it was resolved successfully with endovascular treatment.[ncbi.nlm.nih.gov]
  • Extracranial vertebral artery aneurysm is rare, but the mortality of ruptured cases is extremely high, so early diagnosis and early treatment are important. The present case shows that endovascular treatment was very effective.[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis is generally poor because the rupture rate is extremely high especially with large or giant aneurysms. However, this case had a good clinical course owing to treatment by parent artery occlusion.[ncbi.nlm.nih.gov]
  • prognosis. 10 Fig. 7 A Hamasaki/2014[62] 56/M 5 Proximal endovascular occlusion,.[medsci.org]
  • The prognosis depends on the course of the underlying lesion. ‎[books.google.com]
  • Older individuals and ones with a higher grade of severity when admitted have a higher chance of a poor prognosis.[brain-surgery.com]
  • Early treatment seems essential for improving prognosis in these patients. 12 However, surgery for aneurysms of the VA-PICA traditionally has been performed in a delayed fashion, several days to weeks after SAH. 1 Treatment of an arterial dissection by[ajnr.org]

Etiology

  • The case presented illustrates that this rare condition should be considered in all patients who have neck masses of undetermined etiology.[ncbi.nlm.nih.gov]
  • We report a 29-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. This patient's aneurysm was definitively treated after a successful balloon occlusion test of his affected vertebral artery.[ncbi.nlm.nih.gov]
  • Penetrating trauma, such as gunshot or stab wounds, is by far the most important cause of VAA, whereas blunt force trauma, atherosclerosis, fractures of the vertebral column, rheumatoid arthritis (RA), and syphilis are described as other potential etiologies[symptoma.com]
  • Here, the relation between the basilar tip aneurysm and hypoplastic left vertebral artery, as well as the role of the hypoplasia in vertebrobasilar insufficiency etiology are discussed.[pulsus.com]
  • Palavras-chave em inglês cerebral angiography/methods cerebrovascular disorders/therapy dissecting aneurysm/therapy subarachnoid hemorrhage/etiology therapeutic embolization/methods vertebral artery/pathology Resumo em inglês Vertebral artery dissections[teses.usp.br]

Epidemiology

  • Cervical artery dissection: pathology, epidemiology and management. Thromb Res . 2009 Apr. 123(6):810-21. [Medline] . Raupp SF, Jellema K, Sluzewski M, de Kort PL, Visser LH. Sudden unilateral deafness due to a right vertebral artery dissection.[emedicine.medscape.com]
  • "Cervical artery dissection: pathology, epidemiology and management". Thromb. Res . 123 (6): 810–21. doi : 10.1016/j.thromres.2009.01.013 . PMID 19269682 . a b c d e f g h i j k l m n o p q r Debette S, Leys D (July 2009).[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Intraoperative and postoperative changes in the LSRs provided useful information regarding the pathophysiology of hemifacial spasm.[ncbi.nlm.nih.gov]
  • Surgical Neuroangiography: Clinical and Interventional Aspects in Adults covers a variety of protocols and strategies combining functional vascular anatomy with a complete appreciation of the various disease processes, their pathophysiology, clinical[books.google.ro]
  • Stroke: Pathophysiology, Diagnosis and Management . London, England: Churchill Livingstone; 1986. Vol 1: 549-619. Condie J, Shaibani A, Wainwright MS.[emedicine.medscape.com]
  • However, risk factors and the underlying pathophysiology of vertebral artery dissection and aneurysms differ.[bcidaho.com]
  • "Pathophysiology and risk factors of cervical artery dissection: what have we learnt from large hospital-based cohorts?". Current Opinion in Neurology . 27 (1): 20–8. doi : 10.1097/wco.0000000000000056 .[en.wikipedia.org]

Prevention

  • To prevent neurological deficits we employed electrophysiological monitoring while clipping an aneurysm of the vertebral artery. A 64-year-old woman had suffered a sudden severe headache in the morning.[ncbi.nlm.nih.gov]
  • The patient was treated with endovascular coil embolization to prevent re-rupture. Postoperatively, her right neck and shoulder pain improved, and she was discharged without further neurologic deficits.[ncbi.nlm.nih.gov]
  • If the dissection site was demonstrated to be enlarged on magnetic resonance imaging and magnetic resonance angiography without the manifestation of new symptoms, the patients received additional treatment to prevent bleeding.[ncbi.nlm.nih.gov]
  • Basically, trapping of the TL aneurysm is recommended to prevent regrowth. However, contrived proximal clipping is thought to be suitable for some asymptomatic TL aneurysms, which themselves exhibit perforating arteries.[jstage.jst.go.jp]
  • The treatment was efficient in preventing recurrent hemorrhage and promoting pseudoaneurysms thrombosis, besides it was a safe treatment option.[teses.usp.br]

References

Article

  1. Ravi Kumar CV, Palur RS, Satish S, Rao BR. Vertebral artery aneurysms. Neurol India. 2000;48(2):161-163.
  2. Kao CL, Tsai KT, Chang JP. Large Extracranial Vertebral Aneurysm: with Absent Contralateral Vertebral Artery. Tex Heart Inst J. 2003;30(2):134-136.
  3. Taha MM, Sakaida H, Asakura F, et al. Endovascular management of vertebral artery dissecting aneurysms: review of 25 patients. Turk Neurosurg. 2010;20(2):126-135.
  4. Stavrinou LC, Stranjalis G, Stavrinou PC, Bontozoglou N, Sakas DE. Extracranial Vertebral Artery Aneurysm Presenting as a Chronic Cervical Mass Lesion. Case Rep Med. 2010;2010:938219.
  5. Anand VK, Raila FA, McAuley JR, Reed JM. Large pseudoaneurysm of the extracranial vertebral artery. Otolaryngol Head Neck Surg 1993;109:1057–1060.
  6. Lee JW, Jung JY, Kim YB, Huh SK, Kim DI, Lee KC. Spontaneous Dissecting Aneurysm of the Intracranial Vertebral Artery: Management Strategies. Yonsei Med J. 2007;48(3):425-432.
  7. Haneline MT, Rosner AL. The etiology of cervical artery dissection. J Chiropr Med. 2007;6(3):110-120.

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Last updated: 2018-06-21 21:42