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Cervical-artery dissection (CAD) is a major cause of cerebral ischaemia in young adults and can lead to various clinical symptoms, some of which are benign (eg, headache, neck pain, Horner's syndrome, and cranial-nerve palsy), but most patients have a stroke or transient ischaemic attack. In addition to trauma to the neck, other risk factors have been suggested, such as infection, migraine, hyperhomocysteinaemia, and the 677TT genotype of the 5,10-methylenetetrahydrofolate reductase gene ( MTHFR 677TT), although evidence is sparse. An underlying arteriopathy, which could in part be genetically determined, is believed to have a role in the development of CAD. Importantly, both research on and optimum management of CAD strongly rely on diagnostic accuracy. Although the functional outcome of CAD is good in most patients, socioprofessional effects can be important. Incidence of the disorder in the general population is underestimated. Mortality and short-term recurrence rates are low but possibly also underestimated. Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.

Background Bow Hunter’s syndrome (BHS), also known as rotational vertebral artery occlusion (RVAO), is a rare condition characterized by dynamic vertebrobasilar insufficiency due to position-dependent occlusion of the vertebral artery (VA). In the existing literature, most cases of BHS are attributed to osteophytic compression originating from the occipital condyle or within the transverse foramen, often accompanied by anatomical abnormalities of the VA. However, cases presenting solely with VA anomalies in the absence of any cervical vertebral structural abnormality are rare. This case report presents a unique instance of BHS in a 56-year-old male, attributed to the anomalous origin of the right VA and the absence of the left VA, without cervical structural abnormalities. Case presentation The patient exhibited symptoms like episodic dizziness and vertigo, which were exacerbated by rightward head rotation and alleviated upon returning to a neutral position. Diagnostic evaluation, including digital subtraction angiography, revealed that the right VA originated from the right common carotid artery and compression-induced stenosis of the right VA during head rotation. Conservative management, including avoidance of certain head movements and anti-arteriosclerosis medication, led to symptom resolution over a two-year follow-up period. Conclusions This report contributes to the understanding of BHS by highlighting a rare vascular anomaly presentation and incorporates a review of 14 similar case reports in the literature describing that an anatomical abnormality of the VA is mainly responsible for the pathology of BHS in the absence of cervical vertebral anomalies, thus emphasizing the need for careful diagnostic and management strategies.

High-resolution magnetic resonance imaging (HR-MRI) can provide valuable insights into the evaluation of vascular pathological conditions, and 3D digital subtraction angiography (3D-DSA) offers clear visualization of the vascular morphology and hemodynamics. This study aimed to investigate the potential of a multimodal method to treat unruptured vertebral artery dissection aneurysms (u-VADAs) by fusing image data from HR-MRI and 3D-DSA. This observational study enrolled 5 patients diagnosed with u-VADAs, who were scheduled for interventional treatment. The image data of HR-MRI and 3D-DSA were merged by geometry software, resulting in a multimodal model. Quantified values of aneurysm wall enhancement (AWE), wall shear stress (WSS), neck velocity, inflow volume, intra-stent flow velocity (ISvelocity), and intra-aneurysmal velocity (IAvelocity) were calculated from the multimodal method. We found the actual lengths of u-VADAs in the multimodal model were longer than the 3D-DSA model. We formulated surgical plannings based on the WSS, IA velocity, and neck velocity. The post-operative value of IAvelocity, neck velocity, and follow-up quantified values of AWE were decreased compared with the pre-operative condition. After that, u-VADAs were complete occlusion in four patients and near-complete occlusion in one patient during the 6th-month follow-up after surgery. The multidimensional method combining HR-MRI with 3D-DSA may provide more valuable information for treating VADAs, with the potential to develop effective surgical planning. •A specific method that combines HR-MRI and 3D-DSA to accurately correlate the locations of AWE and intimal tears.

Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines—based on available evidence from mostly observational studies—suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0–3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI −4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

ObjectiveTo evaluate the outcomes of flow-diverting device (FDD) treatment for large vertebral artery dissecting aneurysms (VADAs).MethodsThis retrospective study evaluated 12 patients with 12 VADAs who were treated using FDD between 2013 and 2020. Clinical and radiographic data, including procedure-related complications and clinical outcomes assessed using the modified Rankin Scale (mRS) at the time of the last follow-up, were collected and reviewed.ResultsAll 12 patients had unruptured aneurysms. There were 3 (25%) female and 9 (75%) male patients, and the mean patient age was 54.6 years. The mean size of the aneurysm was 15.9 ± 4.8 mm. The mean follow-up duration was 15.8 months. Single FDD without additional coils was used in all patients. One patient underwent second-line treatment with FDD for recurrence of large VADA after stent-assisted coiling. Immediate follow-up angiography after placement of the FDD demonstrated intra-aneurysmal contrast stasis. There were 2 (17%) patients who had peri-procedural stroke. Angiography at the 6-month follow-up in 10 patients showed favorable occlusion (OKM grade C3 + D). A total of 11 (92%) patients had good clinical outcome (modified Rankin Scale ≤ 2) at the last follow-up. No re-treatment or delayed aneurysm rupture occurred during the follow-up period.ConclusionsReconstructive technique with FDD is a feasible and effective modality for the treatment of large VADAs, showing favorable occlusion rate and clinical outcome.

The use of four consecutive flow diverter stents to treat a giant unruptured fusiform vertebrobasilar dissecting aneurysm (VBDA) is extremely rare, and their safety and efficacy have not been fully established. This case report describes the case of a middle-aged Chinese male patient who underwent endovascular treatment for a giant unruptured fusiform VBDA using four flow diverter stents deployed in a bridging sequence. Digital subtraction angiography revealed a fusiform aneurysm extending from the V4 segment of the left vertebral artery to the mid-basilar artery, measuring approximately 7.90 mm × 64.5 mm. The procedure achieved complete aneurysm occlusion and satisfactory arterial remodeling without significant thrombosis. The patient successfully underwent endovascular treatment with four flow diverter stents, resulting in stable flow in the reconstructed parent artery. At 12-month follow-up, no new neurological deficits were observed. This case provides valuable insights into the management of giant unruptured posterior circulation fusiform aneurysms, particularly in patients with well-developed bilateral vertebral arteries and posterior inferior cerebellar arteries.

Flow diverters (FDs) have been employed in the treatment of unruptured intracranial vertebral artery dissecting aneurysms (IVADAs), yielding seemingly favorable outcomes. Despite FD treatment, aneurysm persistence (incomplete occlusion post-initial treatment) can occur in some patients, potentially leading to recurrent symptoms or complications. This study aims to explore the risk factors associated with the persistence of unruptured IVADAs that have undergone treatment with FDs. The study encompassed 77 unruptured IVADAs from 75 consecutive patients who received treatment with FDs. At a median follow-up of 13 months, 31.2% (24/77) of IVADAs exhibited persistence. Upon multivariate logistic regression analysis, significant pre-procedural stenosis adjacent to aneurysmal dilatation (odds ratio [OR] 17.02, 95% confidence interval [CI] 2.01–144.24, p  = 0.009) and posterior inferior cerebellar artery involvement (OR 7.06, 95% CI 1.40–35.50, p  = 0.018) were independently associated with aneurysm persistence; while follow-up duration (OR 0.91, 95% CI 0.84–0.97, p  = 0.005) was adversely associated with aneurysm persistence. Significant pre-procedural stenosis adjacent to aneurysmal dilatation and posterior inferior cerebellar artery involvement could serve as independent risk factors contributing to the persistence of unruptured IVADAs after FD treatment. .

Vertebral artery (VA) duplication is an infrequent vascular variation with a dearth of information on hemodynamic parameters. In this study, color Doppler ultrasonography was utilized to evaluate the origins and hemodynamic features of VA duplication to offer a solid reference for clinicians who are endeavoring to gain insights into this particular form of vascular anomaly. A retrospective analysis was conducted on patients with VA duplication detected by color Doppler ultrasonography. The analysis focused on the origins, the transverse course, diameter and the peak systolic velocity (PSV) of each segment of the duplicated VA. In the 36 branches in 18 subjecte identified as VA duplication, 27 branches originated from the subclavian artery and 9 branches originated from the aortic arch. The incidence of variation in the non-C6 entry of the medial branch was 94.4%. Significant differences (P < 0.01) were found in the diameter between the lateral and medial branches, as well as between the medial branch and the convergent VA. Moreover, significant differences in PSV were noted between the medial and lateral branches (P = 0.035) and between the medial branch and the convergent VA (P = 0.015). VA duplication is correlated with substantial alterations in both the origin and the entry level into the transverse foramen. In our case series of VA duplication, the diameter and PSV of the medial branch is different from that of the convergent VA or the lateral branch, which might be useful for neuro-interventionalists and neck surgeons.

Aberrant origin of vertebral artery is rare. The anatomical features and clinical significance of this lesion remain to be clarified. A comprehensive collection of the pertinent literature resulted in a cohort of 1286 cases involving 955 patients and 331 cadavers. There were more left than right and more unilateral than bilateral aberrant vertebral arteries. Patients with aberrant origin of vertebral artery were often asymptomatic and in only 5.5% of the patients their symptoms were probably related to the aberrant origin of vertebral artery. The acquired cardiovascular lesions were present in 9.5% of the patients, 20.9% of which were vertebral artery-associated lesions. Eight (0.8%) patients had a vertebral artery dissection. Logistic regression analysis showed significant regressions between bovine trunk and left vertebral artery (P=0.000), between the dual origins of vertebral artery and cerebral infarct/thrombus (P=0.041), between associated alternative congenital vascular variants and cervical/aortic dissection/atherosclerosis (P=0.008). Multiple logistic regression demonstrated that side of the aberrant origin of vertebral artery (left vertebral artery) (P=0.014), arch branch pattern (direct arch origin) (P=0.019), presence of the common trunk (P=0.019), associated acquired vascular disorder (P=0.034) and the patients who warranted management (P=0.000) were significant risk predictors for neurological sequelae. The patients with neurological symptoms and those for neck and chest operations/ interventions should be carefully screened for the possibility of an aberrant origin of vertebral artery. The results from the cadaver metrology study are very helpful in the design of the aortic stent. The arch branch pattern has to be taken into consideration before any maneuver in the local region so as to avoid unexpected events in relation to aberrant vertebral artery.

Abstract BACKGROUND The natural course of unruptured vertebral artery dissecting aneurysms (VADAs) remains unclear. OBJECTIVE The purpose of this retrospective study was to develop a strategy for treating unruptured VADAs based on long-term follow-up. METHODS Our study population consisted of 100 patients with unruptured VADAs; in 66, the initial symptom was headache only, 30 presented with ischemic symptoms and 4 with mass effect. All underwent magnetic resonance imaging and magnetic resonance angiography at the time of admission and 2 weeks and 1, 3, 6, 12, and 24 months after the onset. 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. RESULTS Of the 100 patients, 4 underwent early intervention because of symptom exacerbation. The other 96 were initially treated conservatively; during follow-up, 5 manifested lesion enlargement on magnetic resonance angiography. Nine patients received additional treatment; 1 underwent direct surgery with trapping of the dissection site, and 8 underwent coil embolization. The other 91 patients continued to be treated conservatively; the dissection site remained unchanged in 70, improved or healed in 18, and disappeared in 3 patients. We treated 38 patients with recurrent ischemic attacks with antiplatelet therapy. No patients experienced bleeding or permanent neurological deficits during follow-up. CONCLUSION The nature of an unruptured VADA is not highly aggressive. However, if the dissection site enlarges without the manifestation of new symptoms, it should be occluded. In patients with recurrent ischemic attacks antiplatelet therapy should be considered.