ORIGINAL ARTICLES  VASCULAR PAPERS 

The Journal of Cardiovascular Surgery 1999 June;40(3):395-400

Copyright © 2000 EDIZIONI MINERVA MEDICA

language: English

Surgical decompression of the first part of vertebral artery for ischemic brainstem dysfunction

Hurvitz S. A.*, Bonecutter G. E.

From the Department of Surgery*, Rancho Los Amigos Medical Center, Downey, California, USA

Background. Ischemic brain­stem dys­func­tion can be ­caused by extrin­sic com­pres­sion or kink­ing of the prox­i­mal ver­te­bral ­artery. This is a ret­ro­spec­tive sur­vey of oper­at­ed ­patients com­par­ing neu­ro­log­ic exam­ina­tions ­done post­op­er­a­tive­ly ­with preoper­a­tive neu­ro­log­ic eval­u­a­tion. No ­patient ­with arte­rio­scle­rot­ic obstruc­tion of the prox­i­mal ver­te­bral ­artery treat­ed by endar­te­rec­to­my is includ­ed in ­this ­series.
Methods. Over a 5 ­year peri­od, 104 ­patients pre­sent­ed preoper­a­tive­ly ­with ­signs and symp­toms of brain­stem dys­func­tion, ­with neg­a­tive com­pu­ter­ized tom­o­graph­ic ­scans of the ­brain, and angio­gra­phy ­which dem­on­strat­ed radio­graph­ic find­ings com­pat­ible ­with imped­i­ment to and com­pro­mise of ­blood ­flow ­into the ­first ­part of the ver­te­bral ­artery. All ­patients had sur­gi­cal explo­ra­tion of the prox­i­mal ver­te­bral ­artery in the low­er ­neck main­ly ­under ­local infil­tra­tive anes­the­sia. Extrinsic com­pres­sion or kink­ing of the prox­i­mal ver­te­bral ­artery was ­found in all ­patients and ­relieved by sur­gi­cal decom­pres­sion and arter­i­ol­y­sis. Thirty-­eight (36%) of the 104 ­patients had ­staged bilat­er­al ver­te­bral ­artery decom­pres­sion and arter­i­ol­y­sis.
Results. There was no oper­a­tive mor­tal­ity and ­only min­i­mal mor­bid­ity in ­this ­series. Twenty ­four ­patients had post­op­er­a­tive aor­tic ­arch angio­gra­phy ­which ­showed ­absence of any radio­graph­ic abnor­mal­ities ­seen pre- oper­a­tive­ly, and ­which fur­ther ­showed a ­more direct­ly ­aligned ­flow ­path of the prox­i­mal ver­te­bral ­artery ­with the sub­cla­vian ­artery. The one ­year post­op­er­a­tive ­results in the 104 ­patients ­were as fol­lows: 71 (68%) had sus­tained par­tial res­to­ra­tion of ­lost neu­ro­log­ic func­tion, 23 (22%) had no ­change in neu­ro­log­ic stat­us, and 10 (10%) ­became ­worse in neu­ro­log­ic stat­us. In the ­group of 71 ­patients who had sus­tained par­tial res­to­ra­tion of ­lost neu­ro­log­ic func­tion for 1 ­year post­op­er­a­tive­ly, 19 ­patients ­were neu­ro­log­i­cal­ly eval­u­at­ed for ­from 16 to 20 ­years post­op­er­a­tive­ly and con­tin­ued to exhib­it sus­tained par­tial res­to­ra­tion of ­lost neu­ro­log­ic func­tion ­over ­that ­time.
Conclusions. A ­safe, effec­tive sur­gi­cal pro­ce­dure ­that can be per­formed ­under ­local anes­the­sia, name­ly decom­pres­sion and arter­i­ol­y­sis of the prox­i­mal ver­te­bral ­artery, is avail­able for the treat­ment of ischem­ic brain­stem dys­func­tion ­caused by extrin­sic com­pres­sion or kink­ing of the prox­i­mal ver­te­bral ­artery.