Medullary Decompression by Sling Repositioning of Vertebral Artery with Operative Video

Vascular compression of the medullary pyramid resulting in neurologic compromise is rare; therefore diagnosis is difficult and ultimately delayed. Most patients present with a combination of cranial nerve, autonomic, and/or motor and sensory dysfunction. Presentation with a single sign such as hemiparesis is rare. The low number of cases reported has made it impossible to define a standard treatment for this unusual disorder.

Here, we present a patient with progressive left hemiparesis due to compression of the upper medulla by the vertebral artery, which was treated with repositioning of the artery using a sling. Clinical and radiologic features including upper medullary compression by the left vertebral artery with effacement of the left medullary pyramid and T2/fluid-attenuated inversion recovery signal changes in the right medulla are illustrated. The patient underwent a standard left retrosigmoid craniectomy for mobilization of the left vertebral artery with a Hemashield (Maquet Cardiovascular, San Jose, California, USA) sling (see video). Postoperatively, the patient had significant improvement of the left hemiparesis and follow-up imaging showed decompression of the medulla with edema reduction.

Vascular decompression using a sling has proven to be a valuable option for treatment of symptomatic vascular brainstem compression.