ELSEVIER

Anatomy

MICROSURGICAL
ANATOMY
OF
THE ATLANTAL
PART OF THE
VERTEBRAL
ARTERY
Tarik H. Abd El-Bay, M.D.; Manuel Dujovny, M.D.; and James I. Ausman, M.D., Ph.D.
Department of Neurosueery, University of Mnois at Chicago, Chicago, Illinois

Abd El-Bary TH, Dujovny M, Ausman JI. Microsurgical anatomy of

the atlantal part of the vertebral artery. Surg Neurol1995;44:392401.
BACKGROUND

Microanatomy of the vertebral artery has been the subject of multiple studies. However, none of them has covered every aspect of microvascular anatomy of the atlantal part of the vertebral artery.
MATERIALS

AND

METHODS

Microsurgical anatomy of the atlantal part of the vertebral artery was studied in 14 cadaveric specimens. The
artery was dissected using the standard microsurgical
technique under operative microscope magnification.
The atlantal part of the vertebral artery was divided into
five segments:the foraminal, sagittal, transverse, medial
condylar, and dural. The length of each segment was
measured, as was the diameter of the artery. The
branches of this part of the artery were identified and the
distance between the point of dural entry of the artery
and the midline of the atlantooccipital dura was measured. Distance between the mastoid tip and the artery
and the distance between the mastoid tip and the tip of
Cl transverse process were measured.
RESULTS

Results of all measurements are summarized in tables

and text. We discuss various anomalies, branches, and
lesions of the vertebral artery and surgical approaches
with new methods of managing diseasesin this area.
KEY WORDS

Atlantai, microanatomy, vertebral artery.

he object of this study was to detail the microvascular anatomy of the atlantal part of the
vertebral artery (VA). Although this section of the
artery has been studied before, to our knowledge
none of these studies covered the atlantal part in
every aspect [9,15,16,25,28]. Being deeply buried at
the craniocervical
junction, an area where large
varieties of lesions are found, a thorough study of
Address reprint requests to: Manuel Dujovny, M.D., Neuropsychiatric
Institute, The University
of Illinois at Chicago, Department
of Neurosurgery (M/C 799). 912 South Wood Street, Chicago, IL 60612-7329.
Received December 17, 1993; accepted January 1, 1995.
00903019/95/$15.00
SSDI 0090-3019(95)00035Z

its anatomic structures may make surgical interventions less complicated.

The vertebral
artery is traditionally
divided
into four segments. In the first segment, the artery
angles dorsally from its origin at the subclavian
artery until it enters the transverse foramen of
the C6. The second segment lies within the transverse foramen from C6 to C2. The third portion is
the distal extracranial
segment that is short and
tortuous.
The artery passes through the transverse foramen
of the atlas and then bends
abruptly around the superior articular process of
the atlas. It then makes a sharp turn to pierce the
dura mater,
thereby
entering
the cranium
through the foramen magnum.
The fourth segment is entirely intracranial
and terminates
when
the vertebral arteries join at the medullopontine
junction to form the basilar artery [4,16].

MATERIALANDMETHODS
This study was performed on 14 cadaveric specimens having no history of craniocervical pathology.
The ages of the specimens were not defined. Vertebral artery measurements
and anatomic relationships were studied under an operative microscope
(OPMI I-SH: Carl Zeiss Inc., New York, NY) with a
video camera recording (Hitachi Denshi, Ltd., Japan). Dissection was made using microsurgical
instruments. The atlantal part of the third portion of

the VA was divided

(Figure 1):

into five segments,

as follows

Foraminal segment: From point of entry to Cl transverse foramen to the point of direction change
from vertical to posterior in the sagittal plane.
SagittaI segment: From the end of the first segment
to the change of direction from the sagittal to the
transverse in the horizontal plane above the Cl
posterior arch.
655 Avenue

0 1995 by Elsevier Science Inc.

of the Americas, New York, NY 10010

Microsurgical

Anatomy of the Vertebral Artery

Surg Neurol
1995;44:392-401

Vertebral Artery (Atlantal Part) (mm)

SEGMENT

-Fs

Drawing of atlantal part of vertebral artery (VA)

showing different segments: foraminal (Fs), sagittal
(Ss), transverse (I?.), medial condylar @KS), and dural
(Ds). The dura mater is opened posteriorly and the intradural vertebral artery is shown to go anterior to the brain
stem (from Lang [17] with modification, 41).

Transverse segment: Starting from the end of the

second segment and running an arched course
above the Cl posterior arch with part of its
course in the transverse groove of atlas vertebra
to the direction change from transverse to vertical medially to the lateral mass of the atlas.
Medial condylar segment: From the end of the third
segment and running superomedially
to the atlanto-occipital
joint and occipital condyle, entering the dura at the lateral margin of the foramen
magnum.
Dural segment: The part of the artery surrounded
by dural sheath.
The specimens were positioned
supine with a
30-degree head tilt to the other side during skin
incision and muscle dissection. The head tilt was
increased up to 75 degrees while dissecting the
artery and taking the measurements.
We removed part of the posterior arch of Cl and
unroofed the Cl transverse foramen to facilitate
taking measurements.
The branches of this part of
the artery were studied, and the relations to the Cl
nerve, vertebral venous plexus, and the mastoid
process were identified.
MEASUREMENTS
The length of each segment was measured except
for the third segment; because of its curved course,
the distance between the end of the sagittal segment and the beginning of the fourth segment was
measured instead. In the dural segment the length
of the dural sheath medial and lateral to the artery

393

Foraminal
Sagittal
Transverse
Medial condylar
Dural
Medial side
Lateral side

LEFT
MEAN
RANGE
10

RIGHT
MEAN
RANGE

8-13

10.1

8.5

6-13

8.9

16.6
9.8

13-20
8-12

16.1

8-14
6-l
13-19

8.8

6-14

5
3

46
2-5

4.4
2.7

2-6
1.5-4

was measured (Table 1). The diameter of the artery

was measured at three positions: at the point of
entry to the Cl transverse foramen; at the transverse groove of Cl; and at its dural entry. Five other
distances were measured: the distance between the
point of dural entry and the midline of the atlantooccipital dura; the distance between the point of
direction change of the artery from sagittal to transverse above the Cl transverse foramen and the
mastoid tip; the distance between the tip of the Cl
transverse process and the mastoid tip; the distance between the point of origin of the posterior
meningeal artery and the point of dural entry of the
VA, and the distance between the point of origin of
the muscular branch above Cl and the point of
direction change from sagittal to transverse above
the Cl transverse foramen.

RESULTS
VERTEBRALARTERY
The VA entered the transverse foramen of Cl where
it ran in a vertical and slightly anterior direction.
Just above the Cl transverse foramen, the artery
changed direction dorsally and ran farther in the
sagittal plane. In most cases this change of direction was associated with an acute angle, but in
others it was in a posteromedial
direction. Then the
artery changed direction again and ran transversely
above the posterior arch of Cl. The distance between the mastoid tip and the point of direction
change of the artery from sagittal to horizontal was
2 1 mm (mean) on the left side (12-30-mm range)
and 21.2 mm (mean) on the right side (12-30-mm
range) (Figure 2). This part of the artery ran a
straight or arched course depending on the length
and direction of the second segment of the artery. If
the length of the second part was long the artery
ran in a straight course, and if it was short the
artery ran in an arched course with posterior protrusion above the Cl posterior arch. This posterior

394

Abd El-Bary et al

Surg Neurol
1995;44:392-40 1

of atlantal part of
qtweenVADrawing
showing: distance bemastoid tip and VA; mastoid tip and tip of Cl transverse
process; distance between point
of dural entry and midline of atlanto-occipital dura (from Lang
with modification, 39).

protrusion of the artery was 11 mm in one specimen. In this situation the artery could be injured
during some operations at the craniocervlcal
junction. This part of the artery related anteriorly to the
lateral mass of the atlas and atlanto-occipital
joint.
It passed in the transverse groove above the Cl
posterior arch to the point of direction change from
transverse to vertical at the medial side of the lateral mass of the atlas and occipital condyle. The
direction change usually occurred at the end of the
transverse groove medially but in one specimen it
changed its direction in the middle of the groove.
The artery then passed upward and medially, partially covered by the atlanto-occipital
membrane,
and entered the dura at the lateral aspect of the
foramen magnum. At that part of the artery, the dura
formed a funnel-shaped sheath around the artery.
The length of this sheath was longer medial to the
artery than lateral to it. The distance between the
point of dural entry and the midline of the atlantooccipital dura was 16.8 mm (lo-19.5-mm
range)
(Figure 2). The diameter of the artery was found to
be 4 mm on the left side (2.5~6-mm range) and 3.9
mm on the right (2.3-5.5-mm range); there was no
change of the artery diameter in its atlantal part
(Table 2).
The Cl transverse process has an important role
in the approach to this part of the VA. It is the most
prominent transverse process of the cervical spine
and can be palpated subcutaneously
halfway between the mastoid tip and the angle of the mandible. The distance between the tip of the Cl transverse process and the mastoid tip was measured.
On the left side it was 21 mm (15-30-mm range), on
the right side, 18.8 mm (1 l-25-mm range) (Figure 2).

BRANCHES
As the artery entered the transverse foramen of Cl,
it formed a radiculomuscular
branch below the Cl
posterior arch that ran medially to the atlantoaxial
joint anteriorly and C2 nerve inferiorly. This branch
was found in all specimens. It divided into a dural
branch that entered the dura with the C2 nerve and
muscular branches. This radiculomuscular
branch
originated just at the point of entry of the VA to the
Cl transverse foramen, but in one case it originated
at the lower part of the foramen (Figure 3).
Above the Cl posterior arch the artery formed
another muscular branch directed posterosuperiorly and medially. This branch was found in four
specimens. The point of origin of this artery was
5-10 mm distal to the point of the VA direction
change from sagittal to transverse above the Cl
posterior arch (junction between sagittal and transverse segments) (Figures 3 and 4).
Distal to this branch the VA projected another
branch from the posteromedial
aspect, the posterior meningeal
artery. It traversed
a tortuous
course to enter the dura. The point of origin of this
artery was 7-l 1 mm proximal to the point of dural

Diameter of Vertebral Ariery (mm)

SIDE

Left
Right
Left greater than right
Right greater than left
Left equal to right

MEAN
4

3.9

RANGE
2.5-6
2.3-5.5

42.9%
35.7%

21.4%

Microsurgical

Anatomy of the Vertebral Artery

Surg Neurol
1995;44:392-401

395

(A): Atlanta1 part of VA showing C2 nerve going

1 (A): Sagittal and transverse of atlantal part of VA.
q(RMbr)around
Cl-C2 part of VA. Radiculomuscular branch
0
Muscular branch (Mbr), periosteal sheath (PSh),
at entry to Cl transverse foramen, muscular
venous plexus (VP), and Cl posterior arch. (3): Drawing

branch (Mbr) from transverse part, occipital condyle

(OcC), Cl (Cl) posterior arch, transverse process (fP>,
and atlanto-occipital membrane (AOcM). Cl transverse
foramen is opened posteriorly and part of the posterior
arch of atlas is removed. (B): Drawing of previous figure.

entry of VA. This artery was found on the left side in

four specimens, on the right in six, and absent in

four. The posterior spinal artery originated at the
posteromedial
part of the artery at the point of the
dural entry. It was found on the left side in four
specimens, and on the right in five (Table 3).
VERTEBRAL
VENOUS
PLEXUS
The VA was surrounded by a plexus of veins, continuous with the condylar emissary vein above and
with veins below the Cl posterior arch around the
C2 nerve and the radicular branch of the VA below.
This plexus

drained

into two venous

channels

that

accompanied
ramen of Cl.
or posterior
the foramen

the artery through the transverse foThese two veins were lateral, medial,
but never anterior to the artery inside
(Figure 5).

of previous figure.

PERIOSTEAL
SHEATH
The artery and part of the venous plexus were surrounded by a periosteal sheath that encircled the
whole course of the artery up to the point of dural
entry, where it adhered to the dura mater. This
sheath was calcified, converting
the transverse
groove into a complete tunnel in three specimens,
and into a partial tunnel in four specimens (Figure
6).

Branches of the Atlanta1 Part of Vertebral Artery

NUMBER
BRANCH

Radicufomuscular
Muscular
Postmeningeal
Postspinal

PERCENTAGE

LEFT

RIGHT

LEFT

RIGHT

14
4
4
4

14
4
z*

100
28.6
28.6
28.6

100
28.6
42
35.7

396

Surg Neurol
1995;44:392-401

Abd El-Bar-y et al

(A): Transverse segment of atlantal part of VA after

opening periosteal sheath (PSh) showing venous
plexus (VP) surrounding the artery (VA), and Cl posterior arch (Cl). (B): Drawing of previous figure.

Cl

NERVE

The Cl nerve exited the dura medial to the artery

through the funnel-shaped dural opening. It continued downward and laterally to run inferior and
slightly anterior to the artery in the transverse
groove. At the transverse
groove the nerve
branched around the artery to supply the muscles
of the posterior triangle of the neck. As the VA
enters the Cl transverse foramen the nerve continued anteriorly to the artery and divided into muscular branches (Figure 7).

(A): Transverse of atlantal part of VA, showing calq(Cal.m PSh).

cification of periosteal sheath around the artery
(B): Drawing of previous figure.

DISCUSSION
Within the long history of vascular surgery, the
vertebral artery has a small place due to its deep
location and difficult access for exploration. Sanson
(1836) stated that the VA is beyond the reach of
surgery. Since that date many surgeons have suc-

ceeded in operating on the VA, starting with Maisonneuve (1853) who first successfully ligated the
first portion of the vertebral artery. Later Fenger
(1881) performed a successful ligation on the third

Microsurgical

Anatomy of the Vertebral Artery

B
(A): Atlanta1 part of VA after removal of foraminaf,
sagittal, and half the transverse segment, showing
Cl nerve (Cln) as it goes anteroinferior to artery and
continues laterally to supply muscles in this area. It also
shows condylar vein (CV), Cl posterior arch (Cl), Cl
transverse foramen (TP), Cl transverse process, venous
plexus (VP) and occipital condyle (OcC). (B): Drawing of
previous figure.

part of the artery when he treated a traumatic aneurysm in a 19-year-old man [ 111. In 1888 Matas
described the first operation on an aneurysm of the
distal part of the artery using a posterior approach
[22]. Following this, ligation of the artery was proposed in different cases with various indications:
epilepsy (2) brain tumors (7) and arteriovenous
fistulas (8). A major advance in the diagnosis of VA
diseases was made after the introduction
of angiography [23]. Nevertheless, until the end of the 1950s
surgery of the VA remained directed to arteriovenous fistulas and aneurysms of traumatic origin.
In 1959 Cate and Scott performed the first endarterectomy of the proximal VA [6]. Following the development of vascular surgery, a better understanding
of the role of the VA in cerebral ischemia, and
improvement
in surgical techniques, preservation

Surg Neurol
1995;44:392-401

397

and revascularization
of the VA contributed
to
more effective surgical intervention
in this region.
Artery diameter in our specimens was 4 mm on
the left side and 3.9 mm on the right. Francke and
coworkers found arterial diameters of 4.7 mm on
the left side and 4.3 mm on the right [9]. The vertebral arteries are frequently asymmetric.
Sometimes the minor VA is too small to be detected by
angiography, and it may end in the posterior inferior cerebellar artery. If this minor VA ends in the
basilar trunk it is termed hypoplastic; if it is not
connected to the basilar artery it is termed atretic.
Sometimes the artery may be completely absent. In
that case it is frequently replaced by persistent
congenital anastomoses [35]. There are four possible persistent congenital anastomotic arteries, and
three of them are intracranial:
the trigeminal,
otic,
and hypoglossal. One, the proatlantal,
is extracranial. They represent persistent embryonic anastomotic arteries between the carotid and basilar circulatory systems. The proatlantal is a rudimentary
channel that forms the proximal portion of the occipital artery. The occipital artery originates from
the internal carotid and connects later with the
external carotid artery. This explains why two types
of proatlantal arteries may be observed, one arising
from the external carotid and the other from the
internal carotid. In both types, the artery forms a
sharp curve after its origin to rest upon the supe
rior aspect of the transverse process of Cl. It does
not pass through the transverse foramen of any
vertebra before entering the skull through the foramen magnum, since it joins the normal course of
the VA. In case of a persistent proatlantal artery, the
vertebral artery is absent or hypoplastic. This suggests that the proatlantal artery persists because of
the failure of normal vertebral artery development
[ 18,19,27,29,34,35].
Another anomaly of the VA is duplication
or fenestration of the artery. This is extremely rare in
persons of Western European descent, but in Japanese people it is present in 1% of patients. It occurs
predominantly
in the upper cervical region and is
associated with other intracranial
anomalies. It occurs when a primitive
segmental artery persists
during the embryologic
development
of the artery.
With duplication,
either the main trunk penetrates
the dura at the Cl-C2 levels and the atretic or
hypoplastic
trunk follows the normal course, or
there are two trunks of equal size, one extradural
and the other intradural. This may cause an acute
subdural hematoma
and death, following lateral
cervical spine puncture [30,36,37].
Calcification of the periosteal sheath around the
artery is a common finding. Oliveria and colleagues

398

Surg Neuroi
1995;44:392-401

reported that 28% of their cases had a complete

canal, 24% had a partial canal, and 48% had a shallow groove [25]. Lamberty and Zivanovic reported
in their series that 15% had a complete canal, 22%
had a partial canal, and 63% had a shallow groove
[ 151. Radojevic and Negovanovic found a bony canal bilaterally
in 7% of cases, unilaterally
in 14%,
and an incomplete bony canal in 2% of their specimens [28]. To avoid kinking and subsequent possible brain stem infarction, calcification
of the periosteal sheath and tunneling
of the transverse
groove should be considered during operations requiring mobilization
of the artery, especially if the
artery is the dominant one.
In our study the posterior meningeal artery was
found on the left side in four specimens, on the right
side in six. The meningeal branches of the VA are
usually small, but may become significantly
enlarged in a variety of pathologic conditions.
Both
anterior and posterior meningeal branches arise
from the extracranial VA and supply a portion of the
dura of the posterior fossa. Newton reported the
posterior meningeal
artery on the right side in
29.8% of their cases and on the left side in 40%
(angiographic
study) [24]. This artery originates
from the posterior portion of the VA between the arch
of the atlas and the base of the skull. The artery
courses backwards and upwards toward the posterior rim of the foramen magnum. Its course is
slightly tortuous in its proximal extracranial portion. After entering the skull it assumes a straighter
course extending superiorly, parallel, and close to
the inner table of the occipital bone. It could occasionally be followed to the internal occipital protuberance and, rarely, could be seen extending more
superiorly up to the level of the tentorium
[24].
We found the posterior spinal artery on the left
side in four specimens, and on the right in five. It
usually arose from the posteromedial
surface of the
VA at the point of its dural entry or from the intradural part of the artery [5,25]. In the subarachnoid
space, the artery coursed medially behind the most
rostra1 attachments
of the dentate ligament, and
upon reaching the lower medulla it divided into
ascending and descending branches. The ascending branch coursed through the foramen magnum
and supplied the restiform body, the gracil and the
cuneate tubercles, the rootlets of the accessory
nerve, and the choroid plexus near the foramen of
Magendie, and may have given off branches which
anastomosed with branches of the posterior inferior cerebellar
artery. The descending
branch
passed downward on the posterolateral
surface of
the spinal cord between the dorsal rootlets and the
dentate ligament. It anastomosed with the posterior

Abd El-Bary et al

branches of the radicular arteries that entered the

vertebral foramen at lower levels. The descending
branch gave off collateral branches, each lower one
being smaller and less constant than the previous
one. They coursed medially across the posterior
surface of the spinal cord and joined to form an
artery located in the midline, parallel to the posterior spinal arteries [25].
The posterior inferior cerebellar artery (PICA) is
the largest branch of the vertebral artery; it has a
variable site of origin from the foramen magnum to
the vertebrobasilar
junction. Akar et al found the
artery to originate 16.4 mm (3.0-25.0 mm) from the
vertebrobasilar
junction; none of the PICA originated below the foramen magnum in their study [ 11.
However, Lister et al reported the origin of the PICA
below the foramen magnum in 7 out of 42 PICAS,
and the origin was located 16.9 mm from the
vertebro-basilar
junction (o-35.0 mm range) [20].
Margolis and Newton [21] found the origin of the
PICA between 24 mm below and 45 mm above the
foramen magnum. In their study, 18% of PICAS originated below the level of the foramen magnum, 4%
at the level, and 57% above the level of the foramen
magnum; the site of origin was 16.0 mm (O-35.0-mm
range) from the vertebrobasilar
junction. The PICA
was noted to present as a single artery in 90% of
cases, duplicated in 6%, and absent in 4%. In case of
absent PICA, the anterior inferior cerebellar artery
branches supply the territory of the PICA. Lister et
al divided the PICA into five segments: the anterior
medullary segment in front of the medulla; the lateral medullary segment, which courses beside the
medulla and extends to the origin of the glossopharyngeal, vagal, and accessory nerves; the tonsillomedullary
segment, which courses around the
caudal half of the cerebellar tonsil; the telovelotonsilar segment, which courses in the cleft between
the tela choroidea and the inferior medullary velum
rostrally and the superior pole of the cerebellar
tonsil caudally; and the cortical segment, which
runs over the cerebellar surface [20].
The Cl nerve was found in all cases to exit the
dura medially to the artery, moving anteromedially
to the artery down to the transverse groove, then
inferiorly and slightly anteriorly to the artery in the
transverse groove of Cl. It continued anteriorly to
the artery as it entered the transverse foramen of
Cl. The Cl nerve was formed mainly of anterior
root. The posterior root was inconstant and was
variably found to be intimately related to the presence or absence of connection
with the spinal
nerve. Ouaknine and Nathan reported the absence
of Cl posterior root in 64% of their specimens [26].

Microsurgical

Anatomy of the Vertebral Artery

There are various possibilities

of nerve supply in
areas normally innervated by the Cl posterior root,
as well as the central course of the sensory fibers of
Cl. These possibilities
include a normal course
through the Cl posterior root and connection with
the accessory nerve via anastomosis. The central
fibers still reach the medulla and spinal cord, passing directly into the posterior root, although it is
possible that some fibers reach the medulla with
the accessory nerve. Other possibilities
are that
sensory fibers reach the medulla through the rootlets of the 11th cranial nerve (almost half of all
specimens), and the rest take over the corresponding area of Cl by C2 rootlets that will reach the
spinal cord by the same nerve root or by the 11th
cranial nerve. The Cl posterior root participates in
the innervation of the meninges, the atlanto-occipital
joints, and the area of the occipital for-amen [26].
The neurosurgical
significance of Cl posterior
rootlets becomes apparent in neurotomy
operations. Including these rootlets in radiculotomy
will
avoid residual pain after sectioning C2 and C3 dorsal roots in cases of lesions causing intractable pain
at the craniocervical
junction [26].
The atlantal part of the VA can be approached by
different routes: lateroanterior,
dorsolateral
[ 131,
and posterior [3]. The lateroanterior
approach is
recommended
by many authors [ 10,12,14,32,33,
38,39,40]. It provides relatively easy access to any
part of the VA, from its ostium up to the intracranial
portion, which is wide and safe. This approach
passes through the anatomic plane between the
sternocleidomastoid
muscle and the internal jugular vein without any vessel to dissect. The only
element crossing the field in this approach is the
accessory spinal nerve that has to be freed. In addition, numerous
other structures
can be controlled by the lateroanterior
approach including the
carotid artery, cervical nerve roots, hourglass tumors, and vertebral bodies. Hemilaminectomy
of Cl
and C2, hemicraniectomy,
and infratemporal
ap
proaches follow the same technique
as the lateroanterior approach [ 111. The importance of controlling
the VA without opening the periosteal
sheath must be stressed to avoid problems with the
perivertebral
venous plexus. Moreover, with periosteal dissection the VA is protected surgically.
There are two sites that need particular attention.
The first is the curvature of the VA when it leaves
the groove of the atlas to join the dura mater. There
are two identifying landmarks of this site: change in
height of the posterior aspect of the atlas, which
increases just medially to this point, and a muscular
branch (the suboccipital
artery), which originates
at this point. The second site is the dural penetra-

Surg Neurol
1995;44:392-401

399

tion of the VA. It is not advisable to free the artery

completely at this level, since the periosteal sheath
is particularly adherent to the dura mater. It is safer
to cut the dura mater around but at some distance
from the VA [ 121.
The muscular branch above the posterior arch of
the atlas is usually harvested during exposure of
the artery, and care must be taken not to confuse
the VA with the posterior inferior cerebellar artery
that may rarely originate from the extradural VA
[16,17,20,31,41].
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COMMENTARY
This article by T. H. Abd El-Bar-y and associates is an
important adjunct to our knowledge of the anatomy
of the craniocervical
junction
area. It provides
many precise details and measurements
about the
relationships
of the vertebral artery and the neighboring structures. The upper cervical vertebral artery is a key which provides many possibilities
for
approaching several different areas: the upper cervical spine, the foramen magnum, and the foramen
jugulare. Being able to expose and control the vertebral artery permits one to treat lesions directly
involving this vessel, such as tumors (osseous tumors, sarcomas, extradural Cl or C2 neurinomas,
extradural meningiomas),
craniocervical
junction
malformations,
or infectious processes. In these lesions, generally the entire length of the third vertebral artery segment between C2 and the dura has to
be exposed, and sometimes transposed. Vertebral
artery control improves or provides access to intradural lesions of the foramen magnum to the
odontoid

and anterior

arch of the atlas, and to the

foramen jugulare. Obviously, it also allows one to

suppress the vascular supply of tumors such as
paragangliomas,
or to treat arteriovenous
fistulae,
though endovascular

techniques

most often make it

useless. Finally, the Cl-C2 segment of the vertebral

artery is the site of choice for distal revascularization in case of proximal flow compromise
(ostial
occlusion) or risk of embolism
from vascular lesions (aneurysm) and endovascular treatments. All
these surgical techniques are quite reliable, providing adequate exposure of the vertebral artery is
achieved [ 1,2,3 1. One very important point stressed
by the authors is the periosteal sheath surrounding

Microsurgical Anatomy of the Vertebral Artery

Surg Neurol
1995;44:392-401

the vertebral artery and the venous plexus. In all

cases, the vertebral artery must first be controlled
out of this periosteal sheath to avoid any troublesome bleeding from the venous plexus. If the vessel wall has to be controlled
(for instance, to
perform a venous bypass), the sheath is opened
in a second step. The control of the vertebral
artery requires perfect knowledge of the anatomy
of this vessel, with all possible variations
and
anomalies.
Dr. Abd El-Bary and his colleagues
must therefore be thanked for the anatomic details given in their article, of which any surgeon

working in the region of the craniocervical

tion should be aware.
Bernard

VERY
GUN
THAT
IS FIRED,
EVERY
WARSHIP
LAUNCHED,
EVERY
ROCKET
FIRED,
SIGNIFIES,
IN
THE
FINAL
SENSE,
A THEFT
FROM
THOSE
WHO
HUNGER AND ARE NOT FED, THOSE
WHO
ARE COLD
AND
ARE
NOT
CLOTHED.
THE
WORLD
IN ARMS
IS NOT
SPENDING
MONEY
ALONE.
IT IS SPENDING
THE
SWEAT
OF ITS LABOURERS,
THE GENIUS
OF ITS SCIENTISTS,
THE HOPES
OF ITS CHILDREN.
GENERAL,

junc-

George, M.D.
Paris, France

REFERENCES
1. George B, Laurian C. The vertebral artery: pathology
and surgery. New York: Springer Verlag, 1987.
2. George B, Lot G, Velut S. Tumors of the foramen magnum. Neuorchirurgie 1993;39:1-92.
3. George B, Laurian C. Impairment of vertebral artery
flow caused by extrinsic lesions. Neurosurgery 1989;
24:206-14.

U.S.

401

DWIGHT
D. EISENHOWER
(1890-l
969)
REPUBLICAN
POLITICAN,
PRESIDENT
SPEECH,
APRIL
1953