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

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 preoperatively, 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.