The Vertebral Artery: Pathology and Surgery

266 Pages·1987·0.61 MB·English

by  Bernard George M.D.

T h e
Vertebral
Artery
Pathology and
Surgery
Bernard George
Claude Laurian
Springer-Verlag Wie n New York
Bernard George, M.D.
Department of Neurosurgery, H6pital Lariboisiere, Paris, France
Claude Laurian, M.D.
Department of Vascular Surgery, H6pital Saint Joseph, Paris, France
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With 97 Figures
Library of Congress Cataloging-in-Publication Data.
George, Bernard, 1948- The vertebral artery BIblio
graphy p. Includes mdex 1 Vertebral artery-Surgery 1
Laurian, Claude, 1944- II. Title [DNLM 1 Vertebral
Artery-surgery WG 595 V3 G 346v) RD 598 6 G46 1987
611' 413 87-9521
ISBN-13:978-3-7091-7454-8 e-ISBN-13:978-3-7091-6967-4
001: 10.1007/978-3-7091-6967-4
PREFACE
Our common interest in surgery of the vertebral artery was born in 1976, when as
residents in the same hospital, we attended an attempt by two senior surgeons to
treat an aneurysm of the vertebral artery at the C 3 level. Long discussions had
preceded this unsuccessful trial, to decide if surgery was indicated and to choose
the surgical route. Finally a direct lateral approach was performed, but access was
difficult and correct treatment was impossible, resulting in only partial reduction
of the aneurysmal pouch. Following this experience, we decided to seek a regular
and well defined approach for exposition of the vertebral artery.
Review of the literature indicated some surgical attempts, but the descriptions did
not give the impression of safety and reproducibility. No landmark on the
described surgical route appeared sufficiently reliable. Henry's anatomical work
(1917) gave the only accurate description on vertebral artery anatomy, and it
became the basis for our work.
When the same patient was referred again one year later, after a new stroke in the
vertebro-basilar system, we had behind us repetitive experience on cadavers of an
original approach to the distal vertebral artery.
We are very indebted to Dr. P. Derome and Dr. D. Guilmet for having accepted
the proposals of the two young surgeons we were at the time, thus enabling us to
perform our first revascularization of the distal vertebral artery. With juvenile
enthusiasm, we had proposed and performed what can now be considered the most
difficult technique, i.e. subclavian to distal vertebral artery by-pass because of
absence of both posterior communicating arteries. This first encouraging result
was the beginning of a fruitful and friendly collaboration.
Our increasing experience reported before the French, European and World
societies of neurosurgery and vascular surgery has led many colleagues to consult
us on cases with vertebral artery related lesions. Some referred their patients to us,
others invited us to perform surgery in their center. We were very honored by their
requests for consultation; and our grateful thanks are due to all.
We would also like to express our appreciation for the comprehensive attitude
shown by our head surgeons, Prof. R. Houdart and J. Cophignon in the
Neurosurgery Department of Lariboisiere Hospital and Prof. J. M. Cormier in the
Vascular Surgery Department of Saint Joseph Hospital, who not only permitted
us to initiate and develop the vertebral artery techniques in their departments, but
also gave us their encouragement throughout the past nine years.
VI Preface
We thank for their valuable assistance all our colleagues in Neurology, Neuro
radiology, Functional Investigations, Otolaryngology and Anesthesiology, who
participated in exploring and treating our patients.
Finally, compliments and thanks are due to our two secretaries, Jacqueline
Maurice and Martine Randon, for their inestimable help in preparing the
manuscript, and equally to Mrs. J. Innes for her great assistance in translating and
reviewing the text.
Bernard George
Paris, March 1987 Claude Laurian
CONTENTS
1. Introduction . 1
2. Anatomy 6
2.1. Introduction 6
2.2. Embryology 7
2.3. Structure 7
2.4. Description 8
2.5. Relation to Vascular and Nervous Structures. 14
2.6. Branches 16
3. Congenital Abnormalities 18
3.1. Duplication 18
3.2. Tortuosity and Kinking 19
3.3. Persistent Primitive Arteries 19
3.4. Branches 21
4. Wall Lesions. 23
4.1. Atherosclerosis 23
4.2. Dissection. 26
4.3. Fibromuscular Dysplasia. 34
4.4. Unusual Lesions of the V.A. 40
5. Arteriovenous Malformations 43
5.1. Spontaneous Vertebro-vertebral Fistulas 43
5.2. Traumatic Arteriovenous Fistulas. 45
5.3. Congenital Regional Arteriovenous Malformation or Angio-
dysplasia 54
6. Tumor. 58
6.1. Introduction 58
6.2. Relation to the V.A. 59
6.3. Location of Tumors Involving the V.A. 59
6.4. External Compression. 62
6.5. Histology of Tumors Involving the V.A. 66
7. External Compression. 77
7.1. Second Portion 77
7.2. First Portion . 85
7.3. Third Portion 87
VIII Contents
8. Trauma 90
8.1. Modality 90
8.2. Mechanism 93
8.3. Level of Injury 95
8.4. Onset of Symptoms 95
9. Infancy and Childhood 97
9.1. Traumatic Lesions in the Newborn 97
9.2. Traumatic Lesions in Childhood . 98
9.3. Congenital Arteriovenous Fistula. 100
10. Pathophysiology. 102
10.1. V. A. Preservation. 102
10.2. Prevention of Ischemic Events. 102
11. Pre-operative Investigations. 114
11.1. Morphologic Exams 114
11.2. Functional Examinations. 119
11.3. Interventional Radiology. 123
11.4. Management of Pre-operative Investigations 127
12. Approach to the Cervical V. A. 129
12.1. Historical Background. 129
12.2. General Principles . 130
12.3. Surgical Routes. 134
12.4. Discussion of Surgical Approaches 146
12.5. Surgical Competence . 149
13. Techniques of V. A. Surgery 151
13.1. Introduction. 151
13.2. Wall Lesions. 152
13.3. Arteriovenous Malformations 167
13.4. Tumor. 171
13.5. External Compression. 178
13.6. Intraoperative Embolization. 181
14. Personal Experience 183
14.1. Wall Lesions. 185
14.2. Distal Revascularization 202
14.3. Arteriovenous Malformations 203
14.4. Tumor. 210
14.5. External Compression. 221
14.6. Trauma 224
14.7. V. A. Surgery and Interventional Radiology 227
15. Conclusion 231
References . 233
Subject Index. 254
1. INTRODUCTION
Within the long history of vascular our knowledge, the first successful at
surgery, the vertebral artery (V. A.) tempt to treat a V. A. lesion.
does not occupy a large place. The Some other successes followed: Smyth
relatively minor importance attributed (1864), Barbieri (1867), Kocher (1871).
to the V. A., together with its infre Fenger (1881) was apparently the first
quent pathology, deep location, and to carry out successful ligation of the
difficult access for exploration and sur distal V. A. when he treated a traumatic
gery has led to the accessory place of aneurysm in a 19-year-old man.
V. A. surgery. Compared to the carotid Soon after, in 1888, R. Matas described
artery, developments in physiopa the first direct attack on an aneurysm of
thology, investigation and surgery of the distal part of the V. A. through a
the V. A. have always appeared later. posterior approach.
Today, while carotid artery surgery is Initially and for long after, V. A. sur
routinely performed, V. A. surgery re gery was limited to traumatic lesions,
mains a challenge for most surgeons. and there was debate about the relative
However, as early as 1929, Chiari tried merits of packing of these lesions as
to treat a V. A. lesion. Although he opposed to ligation. Best results seemed
failed, since he ligated the carotid artery to be achieved with packing. As an
with subsequent death, this was nev example, Matas's patient had repeated
ertheless the first recognition of the packing with ice and placement of a 5
need to treat a V. A. lesion (Tables 1 lb. bag of lead shot for compression;
and 2). then, since the patient was still bleed
Subsequently, Dietrich (1831) and ing, he was reoperated and three swabs
Velpeau (1833) attempted ligation of were left in the wound area.
the first and the third part of the V. A., However, even these traumatic lesions
but without success. Following these were very rare, probably because of
failures, Sanson in 1836, thought the poor recognition. Matas noted that his
vertebral arteries were so hidden and patient was the only case ofV. A. injury
inacessible that "they were beyond the reported among 46400 patients treated
reach of surgery". in Charity Hospital of New Orleans
However, in 1853, Maisonneuve dis between 1832 and 1862. Only two V. A.
proved Sanson's pessimism by ligating injuries were recorded during the
the first portion of the V. A. for treat American Civil War (Shumacker,
ment of a traumatic lesion. This was, to 1946); 40 cases during World War I by
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Author Moebus 1827 Chiari 1829 Ramaglia 1834 Cattolica 1836 Cattolica 1836 Yppolito 1838 Stubb 1846 South 1847 Kluyskens 1848 Stone 1849 Branco 1862 Lucke 1867 Stroppa 1867 Gherini 1867 Kocher 1871 Verardini 1872 Weir 1884 Fenger 1881 Simes 1888 Matas 1888
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Table T1. Situation cervical Cl C2 C2 C3 Jaw angle Jaw angle mastoid apex C4 C5 upper cervic. below mastoid back of neck C2 C3 above Cl C4 C5 Cl C2 C5 C6 mastoid below earlobe Cl C2 C5 Cl C2
ex m m m m m m m m m m m m m f m f m m f m
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Age 23 28 20 30 40 23 30 29 23 20 42 33 28 19 41 21
o. 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
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Result died died died died died died died died died died recoverdied died died died died died died died died recoverdied
2 71
5 8
Author Fabricius 1750 1830 Sanson Voisin 1841 Jolly 1841 Thurat 1848 Stromeyer 1850 Maisonneuve 18Watson 1853 Carter 1854 1857 Van Buren 1861 Waren Perrin 1861/62 1862 Kade Prichard 1863 Pirogoff 1864 1865 Peters Barbieri 1867 1867 Saviotti Caspar-Liman 11873 Neuretter King 1885 Kuster 1883
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m CC CC V A CC CC n CC
y fro ment e of e of e of of e ng ng ng ng e of essioof e ng ng
er t ur ur urur gigigigiur prur gigi
al art Trea ligat ligat ligatligat plugplugplugplugligat comligat plugplug
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njuries of the v Cause stab gunshot stab gunshot stab gunshot gunshot stab stab gunshot gunshot tuberculosis gunshot stab gored by OX gunshot stab stab stab tuberculosis stab tuberculosis
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Tab Situation Cl above upper portion C2 C2 C3 upper cervic. Cl C6 C6 C3 C4 C5 C2 C3 C4 C4 above Cl C6 C5 Cl C2 C3 C4 C4 C5 C2 upper cervic. C2
ex m m m m m m f f m m m m m m m m f m m m m f
S
Age Ad Ad 31 58 Ad Ad Ad Ad 25 18 11 Ad Ad 30 Ad 27 20 30 Ad 11 25 35
o. 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
N 1111111111222