HAVE CRANIO-VERTEBRAL JUNCTION ANOMALIES BEEN OVERLOOKED AS A CAUSE OF VERTEBRO-BASILAR INSUFFICIENCY? Deepak Agrawal, Naveen K*, SS kale, C S Bal*, A.

Slides:



Advertisements
Similar presentations
Y. Duan et al. European Journal of Radiology (2011) Changes in cerebral hemodynamics after carotid stenting of symptomatic carotid artery.
Advertisements

Evidence in the ED: “Pain in the Neck” Clearing the C-Collar Yolanda Michetti Dept of EM University of Pennsylvania.
Evaluation and Treatment of the Cervical Spine
Diagnostic importance of contrast enhanced 18 F- fluorodeoxyglucose positron emission computed tomography (FDG PET-ceCT) in patients with tumor induced.
Cervical Spine Clearance “Your Neck is on the Line” James G. Tyburski, MD Detroit Trauma Symposium November 9, 2012.
Subarachnoid hemorrhage
Neurologic Origins of Dizziness & Vertigo Clinical presentations of Dizziness or Vertigo that is of Neurologic Origin  Neurologically mediated dizziness.
Optimal Graft Diameter and Location Reduces Postoperative Complications Following Total Arch Replacement with a Long Elephant Trunk K. Taniguchi K.Toda.
SPECT imaging in cerebrovascular disease Measurement of regional cerebral blood flow (rCBF) Sensitive indicator of perfusion Diagnosis and prognosis of.
A New Way to Evaluate NRC Type Patients thru X-Ray Analysis Dr. Robert DeMartino, D.C., Q.N. Master Trainer for NRCT Superior Health Solutions Henderson,
J. Stephen Huff, MD, FACEP Transient Ischemic Attack Patient Update: The Optimal Management of Emergency Department Patients With Suspected Cerebral Ischemia.
An Overview of Head Injury Management Eldad J. Hadar, M.D. Department of Neurosurgery.
EP 119 Serial Evaluation in Cerebral Perfusion after Indirect Revascularizatition for Children with Moyamoya Disease Using Dynamic Susceptibility Contrast.
Cervical adjacent segment degenerative disease ; Is it a natural history or fusion disease? -comparison between adjacent level of fusion and non-fusion.
Posterolateral versus Posterior Interbody Fusion in Isthmic Spondylolisthesis Introduction Spondylolisthesis is a heterogeneous disorder characterised.
Multislice CT Coronary Angiography
Left facial numbness Ann Schmidt Oct Patient Presentation 54 yo female 54 yo female Left facial swelling, left leg swelling and left arm weakness.
Metastatic Spinal Cord Compression
Dr Kneale Metcalf Stroke Physician (NNUHFT)
Simultaneous Coronary Artery Bypass and Carotid Endarterectomy Ye zhidong, Liu Peng Department of Cardiovascular Surgery China-Japan Friendship Hospital.
CT & MR IMAGING OF NEUROLOGICAL DISEASES IN PREGNANCY AND PUERPERIUM.
Ischemic Stroke without Infarctions: Occlusion and stenosis of carotid arteries ASN Conference September 12 th, 2013.
Qu Xinkai Shanghai Chest Hospital Shanghai Jiaotong University Value of comprehensive cardiac evaluation using MSCT in patients with CTO.
The Role of Thromboprophylaxis in Elective Spinal Surgery The Role of Thromboprophylaxis in Elective Spinal Surgery VA Elwell, N Koo Ng, D Horner & D Peterson.
ROLE OF PIRACETAM IN POST- CONCUSSION SYNDROME A PROSPECTIVE RANDOMIZED STUDY Deepak Agrawal, K Naveen*, CS Bal*, AK Mahapatra Departments of Neurosurgery*
Therapeutic and diagnostic protocol for the treatment of scoliosis associated with Syringomyelia Francesco Lolli, Konstantinos Martikos, Francesco Vommaro,
Pre-Operative Education Guide for Spinal Surgery Patients.
Brain Abscess & Intracranial Tumors
Andrew W. Asimos, MD How Can We Use Advanced Neuroimaging in the ED to Optimize Treatment Options for Acute Stroke Patients?
Dr Hussein Farghaly PSMMC Radionuclide Brain Imaging Master Watermark Image:
VCU DEATH AND COMPLICATIONS CONFERENCE. Complication  Complication  STROKE  Procedure  CEA  Primary Diagnosis  SYMPTOMATIC CAROTID STENOSIS.
PROFILE OF BRAIN ABSCESSES IN PEDIATRIC POPULATION AT AIIMS Agrawal D., Mahapatra A.K., Suri A. Department Of Neurosurgery, All India Institute Of medical.
Diagnosis of Vertebrobasilar Insufficiency Using Transcranial Doppler Ultrasound Sean Steward February 20, 2013.
Central Nervous System
H.Ghanaati; M.D. Associate Professor of Radiology Tehran University Of Medical Sciences Outcomes of intracranial aneurysms treated with coils: A six-month.
Cerebrovascular disease Dr.Nathasha Luke Epidemiology 3rd leading cause of death and disability in the world 3rd leading cause of death and disability.
Certainty of Stroke Diagnosis: Incremental Benefit with CT Perfusion over NC-CT & CTA Richard I. Aviv, Julia Hopyan, Anthony Ciarallo, et al (including.
Peripheral Artery Disease in Orthopaedic Patients with Asymptomatic Popliteal Artery Calcification on Plain X-ray Adam Podet, MS; Julia Volaufova, phD,;
Pulmonary Embolism Pulmonary Embolism Ma hong Depart. of Medical Imaging, Xuzhou Medical College.
Spinal cord compression in spine tumours and injuries Chaloupka, R., Grosman, R., Repko, M., Tichý, V. Ortopedická klinika, FN Brno, Jihlavská 20, 625.
Presenter : Hitesh N. Modi, M.S. PhD Shakti A. Goel MBBS, Hitesh N. Modi M.S. PhD, Bharat R. Dave M.S. MCh., Pankaj R. Patel M.S. Smt NHL Municipal Medical.
Spondylitis. Spondylitis is one of the most common causes of chronic back ache and pain in the neck, making it very difficult for a patient to live a.
Blinded by the Light The irradiation of lenses during routine CT head examinations across a NHS Trust; a quality improvement project Dr Jack Roberts, Dr.
Pulmonary Embolism in Patients with Unexplained Exacerbation of COPD: Prevalence and Risk Factors Isabelle Tillie-Leblond, MD, PhD; Charles-Hugo Marquette,
Clinical predictors of delayed cerebral ischemia after subarachnoid hemorrhage: First experience with coil embolization in the management of ruptured cerebral.
Introduction In the last years several interspinous prostheses have been used for the treatment of several degenerative disc diseases involving the lumbosacralregion;
SFGH Cervical Spine Clearance Protocol
Spinal Imaging and Clearance
MAC Adult Grand Rounds Vestibular/Balance Center Patient
Brain imaging prior to lung cancer resection
Cardiac Indices in Myocardial Perfusion Scan and Their Impact on the Patient's Prognosis
The Value of Measurement of Circulating Tumor Cells in Hepatocellular Carcinoma Nashwa Sheble, Gehan Hamdy, Moones A Obada, Gamal Y Abouria, Fatma Khalaf.
Ectopic Thyroid Gland Intern 陳君豪 2005/08/22.
Evidence-Base Medicine
by: Prof.Dr. Hosna Moustafa Cairo University, Egypt
Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology Effect of a patient-specific minimum activity in stress.
Done By: Dr. Faisal Al-Thekair
Neuroradiology interactive lecture
Neuroradiology interactive lecture
Identification of Spinal Ligamentous Injuries in Trauma
Ms. SHINY THOMAS STAFF NURSE NEUROSURGERY ICU JPNATC, AIIMS New Delhi
Clearing the C Spine in the obtunded patient
The Role of Induced Hypertension and Hyperbaric Oxygen Therapy in Moyamoya Disease: A Case Report Smeer Salam, MD; Lisa Pabst, MD; Sushil Lakhani, MD;
MRI Brain Evaluation of brain diseases Stroke
Changes of Brain Magnetic Resonance Imaging Findings After Congenital Aortic Arch Anomaly Repair Using Regional Cerebral Perfusion in Neonates and Young.
Management of fracture
Dr Rajesh Umap Asso Prof Dept of Radiodiagnosis
MHE diagnosis – Stroop test
Sara K. Fuhrhop, BS Mark J. McElroy, MS Harry C. Dietz, MD
Scoliosis surgery with hybrid system in osteogenesis imperfecta (OI)
Presentation transcript:

HAVE CRANIO-VERTEBRAL JUNCTION ANOMALIES BEEN OVERLOOKED AS A CAUSE OF VERTEBRO-BASILAR INSUFFICIENCY? Deepak Agrawal, Naveen K*, SS kale, C S Bal*, A K Mahapatra Departments of Neurosurgery and *Nuclear medicine, All India Institute of Medical Sciences, New Delhi

BACKGROUND association of VBI with CVJ anomalies is severely underestimated association of VBI with CVJ anomalies is severely underestimated x-rays of the Cx spine are done in only 30% of pts with VBI & only 11% pts have proper flex n /ext n x-rays done x-rays of the Cx spine are done in only 30% of pts with VBI & only 11% pts have proper flex n /ext n x-rays done Lorenstan KJ, Schrospshire LC, Ahn HS. Congenital odontoid aplasia and posterior circulation stroke in childhood. Ann Neurol 1988;

BACKGROUND posterior circulation ischemia has a higher morbidity and mortality posterior circulation ischemia has a higher morbidity and mortality Fifty percent of these patients who are managed conservatively progress to develop infarction Fifty percent of these patients who are managed conservatively progress to develop infarction

BACKGROUND Diagnosing even a percentage of the patients with VBI as having CVJ anomalies may have major therapeutic & prognostic implications. Diagnosing even a percentage of the patients with VBI as having CVJ anomalies may have major therapeutic & prognostic implications.

Aims and Objectives: Using 99Tc ECD brain SPECT to document the presence of posterior circulation cerebral ischemia in patients with CVJ anomalies and correlate with symptoms of VBI. Using 99Tc ECD brain SPECT to document the presence of posterior circulation cerebral ischemia in patients with CVJ anomalies and correlate with symptoms of VBI.

PROSPECTIVE STUDY DONE OVER A SIX MONTH PERIOD PROSPECTIVE STUDY DONE OVER A SIX MONTH PERIOD

STUDY DESIGN 19 PATIENTS WITH FIXED AAD Clinical assessment & Brain SPECT on admission CONTROL GROUP (7 PTS) TOO + PF Rpt SPECT at 4 weeks VBI GROUP (12 PTS) TOO + PF Rpt SPECT at 4 weeks

VBI GROUP Pts with features suggestive of VBI (Drop attacks, episodic vertigo, visual disturbances and dysarthria) Pts with features suggestive of VBI (Drop attacks, episodic vertigo, visual disturbances and dysarthria) CONTROL GROUP patients without symptoms of VBI patients without symptoms of VBI

Operative procedure combined TOO and Occipito-cervical fusion from occiput to C3, using contoured loop and sublaminar wiring with bone graft placement. combined TOO and Occipito-cervical fusion from occiput to C3, using contoured loop and sublaminar wiring with bone graft placement. Both procedures were carried out consecutively in a single sitting. Both procedures were carried out consecutively in a single sitting.

Patients with reducible AAD, requiring only occipito-cervical fusion were excluded from the study to maintain uniformity. Patients with reducible AAD, requiring only occipito-cervical fusion were excluded from the study to maintain uniformity. Postoperatively the neck was immobilized using a philadelphia collar for a period of three months. Postoperatively the neck was immobilized using a philadelphia collar for a period of three months.

SPECT scanning was done using 99Tcm- ECD on a dual headed GE 'Varicam' scanner. The final data was displayed on a 10 grade color scale and semi quantitative analysis performed. The final data was displayed on a 10 grade color scale and semi quantitative analysis performed. SPECT

Regional cerebellar perfusion <10% of contralateral lobe, or in case of bilateral involvement, less than 20% of basal ganglia ABNORMAL SPECT SCAN

OBSERVATIONSRadiology AAD19 AAD19 BI15 BI15 Occipitalisation of atlas14 Occipitalisation of atlas14 kippel-feil anomaly9 kippel-feil anomaly9 cerebellar infarcts2 cerebellar infarcts2 (Both in VBI group)

OBSERVATIONS (VBI Group) Clinical features Vertigo and drop attacks10 Vertigo and drop attacks10 Incoordination8 Incoordination8 visual symptoms4 visual symptoms4

RESULTS (Preoperative SPECT) Decreased cerebellar perfusion in 75% (n=9) of the patients in the VBI group compared to 14% (n=1) in the control group Decreased cerebellar perfusion in 75% (n=9) of the patients in the VBI group compared to 14% (n=1) in the control group (p=0.019, fischer exact, 2 tailed).

RESULTS Following surgery, five patients (55%) in the symptomatic group and none in the control group had improvement in cerebellar perfusion. Following surgery, five patients (55%) in the symptomatic group and none in the control group had improvement in cerebellar perfusion. All five patients showing improvement on SPECT also had improvement in their symptoms of VBI following surgery All five patients showing improvement on SPECT also had improvement in their symptoms of VBI following surgery

Two pts in VBI group developed meningitis in the postoperative period & had a further decrease in cerebellar perfusion on the follow up SPECT scan. Two pts in VBI group developed meningitis in the postoperative period & had a further decrease in cerebellar perfusion on the follow up SPECT scan. Another 2 pts in VBI group had cerebellar infarcts on MRI & did not show improvement in cerebellar hypoperfusion following surgery. Another 2 pts in VBI group had cerebellar infarcts on MRI & did not show improvement in cerebellar hypoperfusion following surgery.

Pathogenesis VBI in CVJ Anomalies Chronic low grade micro-trauma Rptd flex/extn of vessel Intimal damage Thrombosis Embolisation

Clinical rarity of posterior circulation infarcts in CVJ anomalies could be due to: Duplication of VA and the adequacy of the circulation of Willis Duplication of VA and the adequacy of the circulation of Willis patients symptomatic for VBI are not routinely evaluated for CVJ anomalies which remain undiagnosed patients symptomatic for VBI are not routinely evaluated for CVJ anomalies which remain undiagnosed

In patients with CVJ anomalies currently used imaging modalities such as cervical spine x-rays and CT scans are not adequate to evaluate for vertebro-basilar ischemia In patients with CVJ anomalies currently used imaging modalities such as cervical spine x-rays and CT scans are not adequate to evaluate for vertebro-basilar ischemia

Ours is the only study of its kind documenting hypoperfusion in posterior circulation territory in patients with CVJ anomalies. Ours is the only study of its kind documenting hypoperfusion in posterior circulation territory in patients with CVJ anomalies. This hypoperfusion may represent a state of chronic VBI, expected in such patients & MAY BE REVERSIBLE following surgery. This hypoperfusion may represent a state of chronic VBI, expected in such patients & MAY BE REVERSIBLE following surgery.

CONCLUSIONS Our study shows that rigid immobilisation (provided by occipito-cervical fusion in our patients) by itself may confer protection from VBI and direct repair of VA may not be necessary Our study shows that rigid immobilisation (provided by occipito-cervical fusion in our patients) by itself may confer protection from VBI and direct repair of VA may not be necessary

CONCLUSION We strongly recommend that in patients of VBI, a high index of suspicion should be kept for CVJ anomalies and x-rays of the cervical spine with flexion-extension views be done on all patients. We strongly recommend that in patients of VBI, a high index of suspicion should be kept for CVJ anomalies and x-rays of the cervical spine with flexion-extension views be done on all patients.

THANK YOU