Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




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Consultant
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
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KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

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E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : August | Volume : 16 | Issue : 8 | Page : TD01 - TD02 Full Version

Dual Origin of Left Vertebral Artery- A Case Report of an Uncommon Vascular Variant


Published: August 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56325.16705
Chandra Sekhar Patil, S Sushmitha Reddy, Raja Kollu, KS Prashanth Kumar

1. Assistant Professor, Department of Radiology, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 2. Junior Resident, Department of Radiology, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 3. Associate Professor, Department of Radiology, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. 4. Professor, Department of Radiology, Malla Reddy Medical College for Women, Hyderabad, Telangana, India.

Correspondence Address :
Chandra Sekhar Patil,
Assistant Professor, Department of Radiology, Malla Reddy Medical College for Women, Jeedimetla, Suraram, X Road, Quthbulla Pur, Hyderabad-500055, Telangana, India.
E-mail: drchandruhbli@gmail.com

Abstract

Vertebral artery duplication is relatively an uncommon vascular variant. It is a developmental anomaly with a dual origin and has different levels of fusion in the neck. It is usually an incidental finding found during workup of other clinical conditions. Due to its anatomical similarity with arterial dissection, it is often misinterpreted on vascular imaging, so a thorough understanding of this vascular variant is necessary to avoid diagnostic and therapeutic complications during endovascular interventions. A 43-year-old male presented with complaints of pain and discolouration of fingers of left hand since two days. Computed Tomography (CT) angiography of upper limb was done which revealed short segment near complete to complete occlusion/thrombosis of proximal left subclavian artery which was seen 8 mm from its origin with distal reformation by the collaterals. There was an evidence of hypoplastic V1 segment of native left vertebral artery, a small artery was seen arising from the aortic arch in the middle of common carotid and left subclavian artery origins, which was found to be duplicated vertebral artery with dual origin from both the subclavian artery and aorta with fusion of both the limbs at C4-C5 levels

Keywords

Computed topographic angiography, Common carotid, Duplicated left vertebral artery, Left subclavian artery

Case Report

A 43-year-old male presented with complaints of pain and discolouration of fingers of left hand since two days. Computed Tomography (CT) angiography of upper limb was done which revealed short segment near complete to complete occlusion/thrombosis of proximal left subclavian artery (Table/Fig 1) for a length of approximately 13 mm, seen 8 mm from its origin with distal reformation by the collaterals and hypoplastic V1 segment of left native vertebral artery and a small artery was seen arising from the aortic arch in the middle of common carotid and left subclavian artery origins which was found to be duplicated vertebral artery with dual origin from both the subclavian artery and aorta (Table/Fig 2) with fusion of both limbs at C4-C5 level (Table/Fig 3). The patient was conservatively managed with Tab. Clop tap-A (75 mg) (antiplatelet) once a day for six months, Tab. Aerosol-p (analgesic) thrice a day for two weeks and counseled against smoking and on follow-up visit after six months patient was found to be symptom free and stable.

Discussion

Vertebral artery duplication implies dual origin of vertebral artery most commonly from arch of aorta and subclavian artery with fusion at neck level. In 5% of instances, an aberrant origin of vertebral artery can occur directly from the aortic arch (1),(2),(3). The abnormal origin of the vertebral artery is known to exert haemodynamic changes and intracranial abnormalities.

Embryology

Vertebral arteries develop embryo logically from the anastomosis of cervical intersegmental branches. Except for the seventh branch, which gives birth to the subclavian and vertebral arteries, all cervical segments eventually regress, the persistence of these branches predisposes to abnormal variations. The fifth cervical branch can sometimes fail to regress and unite with the seventh cervical branch, resulting in vertebral artery duplication (1).

To avoid inadvertent vessel injury during endovascular interventions and spinal surgeries, a thorough knowledge of this variant is required.

Vertebral arteries usually enter the transverse foramen of C6 vertebrae. Nevertheless, when the left vertebral artery originates from arch of aorta, it usually reaches the C4-C5 vertebrae transverse foramen rather than transverse foramen of C6 vertebra (4). During vertebral artery duplication, one limb may arise from the subclavian artery, while the other may arise either from the arch of aorta, or thyrocervical trunk, innominate trunk, subclavian artery. In extremely rare cases, two limbs of a duplicated left vertebral artery arises from the arch of aorta. The left fourth and fifth intersegmental arteries often branch out from a stem artery that arises from the arch of aorta. The medial limb of the duplicated vertebral artery usually enters the transverse foramen of higher cervical vertebrae, which is consistent with the concept of intersegmental vascular regression failure and is caused by intersegmental arteries that follow the cervical nerve roots (5).

Clinical implications of dual origin of vertebral artery:

1. The limb which is arising from arch of aorta is little longer in length than the other limb arising from subclavian artery hence the risk of atherosclerosis is high in the former limb.
2. Incidence of dissection in duplicated vertebral artery of aortic origin is more than the subclavian origin.
3. Because dual origin can rarely mimic vertebral artery dissection so can be misinterpreted as vertebral artery dissection (6).

In a previous literature, two cases of dual origin of the vertebral artery with dissection have been documented (Table/Fig 4) (1),(3),(7),(8),(9),(10),(11).

Conclusion

Although, dual origin of the vertebral artery is usually an uncommon vascular variant, needs special mention because this variant has got implications with regards to haemodynamics, angiography, endovascular and surgical interventions. Hence, surgeons should be aware of this variant during lower cervical anterior surgery, carotid endarterectomy or other head and neck procedures to prevent damage to the vertebral artery.

References

1.
Satti SR, Cerniglia CA, Koenigsberg RA. Cervical vertebral artery variations: An anatomic study. AJNR Am J Neuroradiol. 2007;28(5):976-80.
2.
Koenigsberg RA, Pereira L, Nair B, McCormick D, Schwartzman R. Unusual vertebral artery origins: Examples and related pathology. Catheter Cardiovasc Interv. 2003;59(2):244-50. [crossref][PubMed]
3.
Kendi AT, Brace JR. Vertebral artery duplication and aneurysms: 64-slice multidetector CT findings. Br J Radiol. 2009;82(983):e216-18. [crossref][PubMed]
4.
Goray VB, Joshi AR, Garg A, Merchant S, Yadav B, Maheshwari P. Aortic arch variation: A unique case with anomalous origin of both vertebral arteries as additional branches of the aortic arch distal to left subclavian artery. AJNR Am J Neuroradiol. 2005;26(1):93-95.
5.
Uflacker R, editor. Atlas of Vascular Anatomy: An angiographic approach. Lippincott Williams & Wilkins; 2007; second edition; chapter-1; p. 4.
6.
Komiyama M, Morikawa T, Nakajima H, Nishikawa M, Yasui T. High incidence of arterial dissection associated with left vertebral artery of aortic origin. Neurol Med Chir (Tokyo). 2001;41(1):08-11. [crossref][PubMed]
7.
Dare AO, Chaloupka JC, Putman CM, Mayer PL, Schneck MJ, Fayad PB. Vertebrobasilar dissection in a duplicated cervical vertebral artery: A possible pathoetiologic association? A case report. Vascular Surgery. 1997;31(1):103-09. [crossref]
8.
Melki E, Nasser G, Vandendries C, Adams D, Ducreux D, Denier C. Congenital vertebral duplication: A predisposing risk factor for dissection. J Neurol Sci. 2012;314(1-2):161-62. [crossref][PubMed]
9.
Kim MS. Duplicated vertebral artery: Literature review and clinical significance. Journal of Korean Neurosurgical Society. 2018;61(1):28. [crossref][PubMed]
10.
Mahmutyaziciog? lu K, Saraç K, Bölük A, Kutlu R. Duplicate origin of left vertebral artery with thrombosis at the origin: Color Doppler sonography and CT angiography findings. J Clin Ultrasound. 1998;26(6):323-25. 3.0.CO;2-K>[crossref]
11.
Panicker HK, Tarnekar A, Dhawane V, Ghosh SK. Anomalous origin of left vertebral artery-embryological basis and applied aspects-A case report. J Anat Soc India. 2002;51(2):234-35.

DOI and Others

DOI: 10.7860/JCDR/2022/56325.16705

Date of Submission: Mar 13, 2022
Date of Peer Review: Apr 27, 2022
Date of Acceptance: May 17, 2022
Date of Publishing: Aug 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 22, 2022
• Manual Googling: May 16, 2022
• iThenticate Software: Jul 20, 2022 (14%)

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