ORIGINAL CONTRIBUTION Vertebral Artery Compression of the Medulla Sean I. Savitz, MD; Michael Ronthal, MD; Louis R. Caplan, MD Background: Intracranial arteries in the subarachnoid Results: We found that compression most commonly oc- space may compress the brain parenchyma and cranial curs at the ventrolateral surface. The clinical features can nerves. Most arterial compressive lesions have been attrib- be transient or permanent and are predominantly motor uted to dolichoectasia in the vertebral-basilar system, and and cerebellar or vestibular, but a poor correlation exists prior reports have concentrated on the pressure effects of between the clinical findings and the severity or extent of basilar artery ectasia. Much less is known about vertebral impingement. The vertebral arteries were angulated, tor- artery compression of the medulla. tuous, or dilated but not necessarily dolichoectatic to cause obvious indentation. Seven patients were treated with an- Objective: To describe a series of patients with verte- tiplatelets and anticoagulants or analgesics, whereas 2 un- bral arteries compressing the medulla oblongata. derwent microvascular decompression, resulting in tem- porary or no relief. One surgical patient developed cranial Design: Prospective case studies. nerve complications. Among the medically treated pa- tients, none had progression of deficits, and those with single Setting: Tertiary care center. episodes had no recurrence of symptoms. Conclusion: This study is the largest collection, to our Patients: Nine symptomatic patients, 4 men and 5 knowledge, of patients with medullary vascular com- women, between the ages of 32 and 79 years. pression. Further studies are needed to estimate its fre- quency, natural course, and preferred management. Main Outcome Measures: Clinical phenomena, ra- diographic findings, treatment, and outcomes. Arch Neurol. 2006;63:234-241 EREBRAL ARTERIES IN THE ated by at least 1 of the authors, including clini- subarachnoid space may cal phenomena, radiographic findings, treat- generate pressure and dis- ment, and outcome. All patients underwent tortion of the brain paren- magnetic resonance imaging (MRI) and mag- chyma and stretching of netic resonance angiography. The main inclu- sion criterion was obvious medullary compres- Cthe cranial nerves. Most intracranial arte- sion by a vertebral artery, which was ectatic, rial compressive lesions have been attrib- tortuous, or dilated. Patients were excluded if uted to dolichoectasia, which refers to di- they had dolichoectasia of the basilar artery or lation, enlargement, and tortuosity of if they had other brain or vascular imaging find- vessels.1 Within the cervicocranial arter- ings that better explained their symptoms and ies, dilatative arteriopathy preferentially in- signs. None of the patients had vascular occlu- volves the vertebrobasilar system. Past re- sive lesions above the vertebral arteries in the pos- ports have emphasized basilar artery ectasia terior or anterior circulation. compressing the pons and cranial nerves ex- iting the pons, causing trigeminal neural- RESULTS gia and hemifacial spasm2-4 and also caus- 3,5 6,7 ing pontine infarcts. Other reports have DEMOGRAPHICS described the general features and clinical symptoms of vertebrobasilar dolichoecta- The clinical characteristics of the 9 pa- sia. Compression of the medulla by dilated tients are summarized in Table 1. There and/or tortuous vertebral arteries is less well were 4 men and 5 women. Ages ranged from known. We report herein a series of pa- 32 to 79 years. There was a bimodal age dis- tients with vertebral arteries compressing the tribution at initial symptom presentation. medulla oblongata. Four patients developed their first symp- Author Affiliations: toms in their 30s, and 5 patients first pre- Department of Neurology, METHODS sented at older than 60 years. There were 8 Beth Israel Deaconess Medical white individuals and 1 African American Center, Harvard Medical From 1998 to 2004, we prospectively collected individual. None of the patients had large School, Boston, Mass. information on 9 symptomatic patients evalu- artery occlusive lesions. (REPRINTED) ARCH NEUROL / VOL 63, FEB 2006 WWW.ARCHNEUROL.COM 234 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 1. Clinical Features and Radiologic Findings Patient No./ Sex/Age, y Medical Conditions Symptoms Neurologic Examination Result Location of Medullary Compression 1/M/71 Hypertension Tinnitus Normal Left lateral surface and pyramid 2/M/79 Hypertension Left leg weakness for 5 min Normal Left lateral surface and pyramid 3/F/35 None Throbbing headaches Normal Tortuous artery indenting on lateral surface and pyramid 4/M/68 Hypertension Sudden 20-s imbalance, Normal Left lateral surface, base, and pyramid veering to the right 5/F/63 Hypertension, DM Sudden left leg tingling Left hemiparesis Right lateral surface, base, and gradual weakness of left and adjacent T2 hyperintensity arm and leg for 3 wk in right medial medulla 6/F/34 None Multiple episodes of Normal Tortuous left vertebral compression unsteadiness, aural fullness, on left side at the base tinnitus, nausea, headache and tegmenta-basal junction 7/F/32 None Hoarseness and dysphagia Vocal cord paralysis, asymmetric S-shaped left vertebral pressing on left lateral left palate elevation surface at middle aspect, sparing pyramids 8/F/63 Hypertension Left arm tingling and left leg Left limb hyperreflexia Left lateral and basilar surface weakness for 2 d 9/F/32 None Episodes of headache, vertigo, LOC Torsional nystagmus to the left, Tortuous, dilated left vertebral compression reduced left corneal reflex on left middle basilar part and pyramid Abbreviations: DM, diabetes mellitus; LOC, loss of consciousness. CLINICAL PHENOTYPES The symptoms and signs of each patient at initial evalu- ation are summarized in Table 1. Three patients had a single episode of symptoms that did not recur, 4 pa- tients had multiple recurrent episodes, and 2 patients sus- tained permanent deficits. Three patients presented with motor limb weakness, 2 ipsilateral and 1 contralateral to the side of compression; 3 patients had vertigo or gait ataxia; 1 patient had hoarseness, vocal cord paralysis, and abnormal palate elevation ipsilateral to the side of com- pression; 1 patient had isolated tinnitus; and 1 patient had only throbbing headaches. BRAIN IMAGING Both MRI and magnetic resonance angiography were performed in all 9 patients. The findings are summa- rized alongside the clinical features in Table 1. Com- pression was present mostly along the lateral surface and involved the pyramids in all patients but the tegmentum in only 1 patient (Figures 1, 2, 3, 4, 5, and 6). All except 1 patient had compression by the left vertebral artery, indenting on the left surface of the Figure 1. A 79-year-old man suddenly developed left leg weakness while medulla. Only 1 patient (patient 5; Figure 4) had a walking. He leaned on a family member for support until the weakness right vertebral artery that compressed the right medul- resolved 5 minutes after onset. Magnetic resonance imaging showed a left lary surface. This patient also had increased signal on vertebral artery pressing on the anterolateral left surface of the medulla. T2-weighted imaging studies within the right medial medulla, representing either wallerian degeneration or damage from branch artery occlusion or compression hoarseness but developed cranial nerve complications and (Figure 4C). Of note, 3 patients had MRIs that showed occipital neuralgia. Patient 9 had temporary relief of symp- enlarged cisterns (Figures 3, 5, and 6). toms, but episodes recurred 4 months after surgery. The 3 patients with single transient episodes treated conser- TREATMENT AND CLINICAL COURSE vatively have not had recurrences to date. Six patients were treated conservatively with analgesics, REPORT OF CASES antiplatelets, and anticoagulants, whereas 2 patients had decompressive surgery (patients 7 and 9 in Table 2). We describe 2 patients to illustrate different clinical Patient 7 had slight postoperative improvement of her features. (REPRINTED) ARCH NEUROL / VOL 63, FEB 2006 WWW.ARCHNEUROL.COM 235 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 A B Figure 2. A 35-year-old woman developed throbbing headaches, although the results of a neurologic examination were normal. Magnetic resonance imaging showed impingement of the left anterolateral surface (A) by an angulated left vertebral artery (B). A B Figure 3. A 68-year-old man developed sudden onset of ataxia, veering to the right, and vertigo for 20 seconds. Magnetic resonance imaging showed severe indentation (A) and displacement to the right of the medulla (B). Patient 4 approximately 20 seconds and did not recur. His neuro- logic examination results were normal. An MRI was ob- A 58-year-old man with hypertension suddenly lost his tained the following day (Figure 3), which showed an ec- balance while standing near his desk at work and felt his tatic left vertebral artery severely compressing the antero- body suddenly being directed to the right. He sensed that lateral medulla. The MRI showed no acute infarcts on the ground was moving underneath him. The episode lasted diffusion-weighted imaging and no hemorrhages on sus- (REPRINTED) ARCH NEUROL / VOL 63, FEB 2006 WWW.ARCHNEUROL.COM 236 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/