Endovascular Approaches: Indications and Techniques

Abstract

The craniovertebral junction is a hinge zone that permits a wide degree of motion of the head via unique biomechanics between the occiput, the atlas and the axis. This transition area encompasses complex vascular and neurological structures. The vertebro-basilar complex, which travels deep into this region surrounding the brainstem in the prevertebral space, is characterized by its elaborated arterial anatomy. This complex is susceptible to a variety of vascular and neoplastic pathologies ranging from an aneurysm of the craniovertebral junction (posterior inferior cerebellar artery, vertebral artery, vertebro-basilar junction) to an arteriovenous malformation, to a thrombotic vessel occlusion or to an encasement by a growing neoplasm. Patients usually manifest with a wide range of symptoms that occur as a result of transient “end-organ” (brainstem, cerebellum, and/or occipital lobes) hypoperfusion. Earlier attempts of treatment have been utterly discouraging. Now that surgeons have an enriched understanding of the topographic and functional anatomy of the craniovertebral confluence, they are capable of overcoming the challenges offered by this pivotal zone and to easily navigate through its formerly unreachable structures. The purpose of this chapter is to portray novel endovascular therapeutic procedures and to discuss their indications in the management of the numerous vascular diseases affecting the craniovertebral junction.