Natello Gregory W, Carroll Christine M, Katwal Arabindra B
Department of Cardiology, William Jennings Bryan Dorn Veterans Affairs Medical Center, USA.
Vasc Med. 2009 Aug;14(3):265-9. doi: 10.1177/1358863X08099707.
We describe a patient with rotational vertebrobasilar ischemia (RVBI) due to vertebral artery (VA) compressive stenoses during neck rotation, complicated by an ostial atherosclerotic stenosis (OAS). Referred for 'near-syncopal spells', inquiry revealed a symptom-complex consistent with vertebrobasilar transient ischemic attacks (TIAs) provoked by head rotation. VA dynamic angiography with imaging via prevertebral subclavian injections in neck-rotated positions while reproducing symptoms, demonstrated two compressive stenoses not present in the neck-neutral position, establishing the diagnosis of RVBI due to CT-demonstrated cervical spondylosis. There was an occluded contralateral VA, isolated posterior circulation, and absent vertebral collateral flow. Disabling symptoms persisted despite using a cervical collar. Surgical decompression of the dynamic stenoses would not address the OAS, was considered high risk, and absence of a suitable donor artery precluded distal VA reconstruction. RVBI resolved with ostial stent placement by improving perfusion pressure across the compressive stenoses. To our knowledge, this is the first report of RVBI in which the affected VA had an obstructive atherosclerotic stenosis in addition to the characteristic rotation-induced dynamic stenoses, and the first report of stent placement in the culprit artery to treat this disorder. Diagnosis depends on recognizing the association of symptoms with positional neck changes and VA dynamic angiography demonstrating the compressive stenosis while reproducing symptoms. This case illustrates the management complexities when there are coexisting abnormalities, emphasizing the need to individualize treatment. RVBI is a potentially correctable cause of TIAs and particularly relevant due to the aging population which has a significant incidence of both degenerative cervical and atherosclerotic cerebrovascular disease.
我们描述了一名因颈部旋转时椎动脉（VA）受压狭窄而导致旋转性椎基底动脉缺血（RVBI）的患者，该患者合并有开口处动脉粥样硬化狭窄（OAS）。患者因“近乎晕厥发作”前来就诊，询问发现其症状复合体与头部旋转诱发的椎基底动脉短暂性脑缺血发作（TIA）相符。在颈部旋转位通过椎前锁骨下注射进行成像的VA动态血管造影，在重现症状时显示出两个在颈部中立位不存在的受压狭窄，从而确立了因CT显示的颈椎病导致的RVBI诊断。对侧VA闭塞，后循环孤立，且无椎动脉侧支血流。尽管使用了颈托，致残症状仍持续存在。对动态狭窄进行手术减压无法解决OAS问题，被认为风险较高，且缺乏合适的供体动脉使得无法进行远端VA重建。通过在开口处放置支架改善了受压狭窄处的灌注压力，RVBI得以缓解。据我们所知，这是第一例受影响的VA除了具有典型的旋转诱发动态狭窄外还存在阻塞性动脉粥样硬化狭窄的RVBI报告，也是第一例在责任动脉中放置支架治疗该疾病的报告。诊断取决于认识到症状与颈部位置变化的关联以及VA动态血管造影在重现症状时显示出受压狭窄。该病例说明了存在共存异常时管理的复杂性，强调了个体化治疗的必要性。RVBI是TIA的一个潜在可纠正病因，鉴于老年人群中退行性颈椎疾病和动脉粥样硬化性脑血管疾病的发病率都很高，这一点尤为重要。
