22 Microsurgical Revascularization of Extracranial Vertebral Artery Disease

Ricardo A. Hanel, Leonardo B.C. Brasiliense, Felipe C. Albuquerque, Andre Monteiro, Guilherme J. Agnoletto, Manuel F. Granja, and Robert F. Spetzler

Abstract

Atherosclerotic disease can affect any segment of the extracranial vertebral artery, though it is most commonly found at its origin. The true incidence is unknown since many patients can be asymptomatic or may present with posterior circulation ischemic symptoms, which can be difficult to diagnose. Vertebrobasilar ischemia can be due to embolic, thrombotic, or hemodynamic phenomena. Understanding the mechanism behind the symptoms is important in order to determine the optimal treatment strategy. Treatment options include optimal medical management, angioplasty and stenting, and open surgical approaches. Data from randomized controlled trials have not yet definitively shown that angioplasty and stenting reduce risk of stroke compared to best medical management and are therefore typically reserved for patients who fail medical therapy. Restenosis after endovascular treatment remains a major limitation. In terms of surgical options, there are no randomized controlled trials comparing surgical intervention to medical management. Surgical strategies include vertebral artery endarterectomy and vertebral artery to carotid artery transposition and are reserved for stenosis at the origin of the vertebral artery. Extrinsic compression of the V2 and V3 segments can be due to cervical spondylosis and instability. They are typically treated with decompression and/or fusion. In this chapter, we review the natural history, treatment indications, and surgical strategies for extracranial vertebral artery stenosis.

Key words

atherosclerotic disease - extracranial vertebral artery - stroke - vertebrobasilar ischemia - microsurgery - revascularization

• 1 Wityk RJ, Chang HM, Rosengart A et al. Proximal extracranial vertebral artery disease in the New England Medical Center Posterior Circulation Registry.. Arch Neurol 1998; 55 (4) 470-478 PubMed

• 2 Diaz FG, Ausman JI. Surgical therapy in vascular brain stem diseases. In: Hofferberth B, Brune GG, Sitzer G, eds. Vascular Brain Stem Diseases. Basel: Karger; 1990

• 3 . Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial.. N Engl J Med 1985; 313 (19) 1191-1200 PubMed

• 4 Compter A, van der Worp HB, Schonewille WJ, et al. Stenting versus medical treatment in patients with symptomatic vertebral artery stenosis: a randomised open-label phase 2 trial.. Lancet Neurol 2015; 14 (6) 606-614 PubMed

• 5 Markus HS, Larsson SC, Kuker W, et al. Stenting for symptomatic vertebral artery stenosis: the Vertebral artery Ischaemia Stenting Trial.. Neurology 2017; 89 (12) 1229-1236 PubMed

• 6 . Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results.. Stroke 2004; 35 (6) 1388-1392 PubMed

• 7 Matsuyama T, Morimoto T, Sakaki T. Comparison of C1–2 posterior fusion and decompression of the vertebral artery in the treatment of bow hunter’s stroke.. J Neurosurg 1997; 86 (4) 619-623 PubMed

• 8 Amarenco P, Hauw JJ. Anatomy of the cerebellar arteries.. Rev Neurol (Paris) 1989; 145 (4) 267-276 PubMed

• 9 Tissington Tatlow WF, Bammer HG. Syndrome of vertebral artery compression.. Neurology 1957; 7 (5) 331-340 PubMed

• 10 Ropper A, Samuels M, Klein J. Adams and Victor’s Principles of neurology. New York, NY: McGraw-Hill Education; 2014

• 11 Abizaid A, Costa MA, Blanchard D, et al. Sirolimus-eluting stents inhibit neointimal hyperplasia in diabetic patients. Insights from the RAVEL Trial.. Eur Heart J 2004; 25 (2) 107-112 PubMed

• 12 Spetzler RF, Hadley MN, Martin NA, Hopkins LN, Carter LP, Budny J. Vertebrobasilar insufficiency. Part 1: microsurgical treatment of extracranial vertebrobasilar disease.. J Neurosurg 1987; 66 (5) 648-661 PubMed

• 13 Albuquerque FC, Spetzler RF. Vertebral artery revascularization.. Operative Techniques in Neurosurgery 2001; 4 (4) 195-201

• 14 George B, Blanquet A, Alves O. Surgical exposure of the vertebral artery.. Operative Techniques in Neurosurgery 2001; 4 (4) 182-194

• 15 Albuquerque FC, Fiorella D, Han P, Spetzler RF, McDougall CG. A reappraisal of angioplasty and stenting for the treatment of vertebral origin stenosis.. Neurosurgery 2003; 53 (3) 607-614, discussion 614–616 PubMed

• 16 Wehman JC, Hanel RA, Guidot CA, Guterman LR, Hopkins LN. Atherosclerotic occlusive extracranial vertebral artery disease: indications for intervention, endovascular techniques, short-term and long-term results.. J Interv Cardiol 2004; 17 (4) 219-232 PubMed

• 17 Chastain II HD, Campbell MS, Iyer S et al. Extracranial vertebral artery stent placement: in-hospital and follow-up results.. J Neurosurg 1999; 91 (4) 547-552 PubMed

• 18 Hanel RA, Brasiliense LB, Spetzler RF. Microsurgical revascularization of proximal vertebral artery: a single-center, single-operator analysis.. Neurosurgery 2009; 64 (6) 1043-1050, discussion 1051 PubMed

• 19 Ford FR. Syncope, vertigo and disturbances of vision resulting from intermittent obstruction of the vertebral arteries due to defect in the odontoid process and excessive mobility of the second cervical vertebra.. Bull Johns Hopkins Hosp 1952; 91 (3) 168-173 PubMed

• 20 Shimizu T, Waga S, Kojima T, Niwa S. Decompression of the vertebral artery for bow-hunter’s stroke. Case report.. J Neurosurg 1988; 69 (1) 127-131 PubMed

• 21 Mapstone T, Spetzler RF. Vertebrobasilar insufficiency secondary to vertebral artery occlusion froma fibrous band. Case report.. J Neurosurg 1982; 56 (4) 581-583 PubMed