Dolichoectasia of the vertebrobasilar complex causing neural compression.

Dear Editor,

We have read with great interest the paper of Yuh et al.[4] reporting a case of symptomatic hydrocephalus due to vertebrobasilar dolichoectasia (VBD) compressing the brainstem.

Ectatic or pathologically enlarged vertebrobasilar arteries have been reported with increasing frequency and associated with several clinical syndromes. These include an assortment of cranial nerve syndromes, transient or permanent motor deficit, cerebellar dysfunction, central sleep apnea, ischemic stroke, hypertension, and hydrocephalus as reported in the paper by Yuh et al.[4]

Others and we have also described pyramidal tract signs and cranial nerve nucleus dysfunction caused by vascular compression of the medulla oblongata by an elongated and ectatic vertebral artery and artery repositioning has proved to be an effective surgical treatment.[23]

We agree with the authors that there is still uncertainty in the optimal treatment of VBD, since there has been no systematic review or long-term results from the different surgical interventions including microvascular decompression (MVD). However, to date, the MVD is the only interventional technique that is able to definitively treat such a pathological condition when associated with symptomatic neural compression.

Neural compression by dolichoectatic vertebrobasilar arteries is an insidious clinical entity presenting several challenges to the neurosurgeon, because the operative procedure not only must be effective in relieving the symptoms, but also must preserve functioning neural and vascular structures. Therefore, the proper management should begin from the first observation of the patient affected by such an abnormality. A careful neurological examination is imperative to ensure that the patient's symptoms are attributable to vascular compression. Neuroradiological investigations are mandatory for diagnosis and surgical planning. With the advent of the magnetic resonance imaging technique, which, using specific three-dimensional sequences, has offered a good visualization of both cranial nerves and cerebral vessels, neurovascular compression disorders have been diagnosed with increasing frequency. In the clinical decision-making process, the neurosurgeon must determine whether the patient's symptoms are significant enough to warrant the surgical intervention. Finally, vessel repositioning must be performed carefully because of the elevated risk of injuring cranial nerves and the small perforating vessels of the vertebrobasilar system.[1]

According to the literature and based on our experience, such a strategy can offer a complete clinical accomplishment with a functional respect of the neural structures.