The Vertebral Artery Pathology and Surgery Bernard George Claude Laurian Springer-Verlag Wi en 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 ThIS work IS subject to copyright All nghts are reserved, whether the whole or part of the maten alls concerned, specifically those of translation, reprmtmg, re-use of Illustrations, broadcastmg, reproduction by photocopymg mach m e or similar means, and storage m data banks 1987 by Spnnger-Verlagj\Vlen Softcover reprint of the hardcover 1 st edition 1987 The use of registered names, trademarks, etc III the publication does not Imply, even III the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use Product LiabIlity The publisher can give no guarantee for Illformatlon about drug dosage and application thereof contamed m this book In every Illdlvldual case the respective user must check ItS accuracy by consultmg pharmaceutical literature With 97 Figures Library of Congress Cataloging-in-Publication Data. George, Bernard, 1948- The vertebral artery BIbliography 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-13:978-3-7091-7454-8 001: 10.1007/978-3-7091-6967-4 e-isbn-13:978-3-7091-6967-4
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, Neuroradiology, 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. Paris, March 1987 Bernard George Claude Laurian
CONTENTS 1. Introduction. 2. Anatomy 2.1. Introduction 2.2. Embryology 2.3. Structure 2.4. Description 2.5. Relation to Vascular and Nervous Structures. 2.6. Branches 3. Congenital Abnormalities 3.1. Duplication 3.2. Tortuosity and Kinking 3.3. Persistent Primitive Arteries 3.4. Branches 4. Wall Lesions. 4.1. Atherosclerosis 4.2. Dissection. 4.3. Fibromuscular Dysplasia. 4.4. Unusual Lesions of the V.A. 5. Arteriovenous Malformations 43 5.1. Spontaneous Vertebro-vertebral Fistulas 43 5.2. Traumatic Arteriovenous Fistulas. 45 5.3. Congenital Regional Arteriovenous Malformation or Angiodysplasia 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. 7.1. Second Portion 7.2. First Portion. 7.3. Third Portion 1 6 6 7 7 8 14 16 18 18 19 19 21 23 23 26 34 40 77 77 85 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