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

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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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




Dr. Mamta Gupta,
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
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!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


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

Important Notice

Experimental Research
Year : 2010 | Month : June | Volume : 4 | Issue : 3 | Page : 2626 - 2631 Full Version

Incidence Of The Anomalous Origins Of The Vertebral Artery – Anatomical Study And Clinical Significance


Published: June 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.767
POONAM, SINGLA R K , SHARMA T

*(Asstt. Prof., MS, Anatomy), Department of Anatomy, Jhalawar Medical College, Jhalawar, Rajasthan(India) **(Associate Prof., MS, Anatomy), *** (Professor, MS, Anatomy) Department of Anatomy, Govt. Medical College, Amritsar, Punjab ,(India)

Correspondence Address :
Dr. Poonam Asstt. Professor, Department of Anatomy
Jhalawar Medical College, Jhalawar (Rajasthan) –
326001Ph. No.: 09602512911, 09799333445,
Email: drpoonamdel@yahoo.co.in

Abstract

Context: The anatomical and the morphological variations of the vertebral artery are significant for diagnostic and surgical procedures in the head and neck region, where an incompatible knowledge can lead to serious implications
Aims: This study was conducted to know the variations in the origins of vertebral arteries and to discuss their clinical implications while performing diagnostic and interventional angiography, both to identify them correctly and to know where to look when vertebral arteries are not seen in the normal position.
Material And Methods: Eighty vertebral arteries belonging to 40 cadavers were dissected in the head and neck region. Their source and mode of origin were studied. Out of the total cadavers, four were found to have abnormal origins of vertebral arteries, which were studied in detail along with their clinical implications.
Results: An extremely rare and interesting case of the origin of the left vertebral artery from the external carotid artery was encountered in one of these specimens. The direct origin of the left vertebral artery from the aortic arch was also found in three cadavers, out of which one was found to be bifurcating after taking origin. No abnormality in the origin was encountered on the right sided vertebral arteries.
Conclusion: The described morphological variations have clinical applications in the wide field of surgery, in the head and neck region. To know about these findings seems to be very important before undertaking any surgery or endovascular treatment in that region. Cerebral angiography must be included in the evaluation of patients with unexplained neurological findings.

Keywords

Subclavian artery, Left vertebral artery, Left external carotid artery, Proatlantal intersegmental artey, carotid-vertebral anastomosis.

Introduction
The vertebral artery, the largest branch of the subclavian artery, arising from the posterosuperior aspect of its first part, 0.5 to 2 cm medial to the thyrocervical trunk, is divided into four segments: (1):
1. Pre vertebral / VI segment: From its origin to the foramen transversarium of the C6 vertebra.
2. Vertebral / V2 segment: From the foramen transversarium of the C6 vertebra till that of the C1 vertebra.
3. Atlanto axial/V3 segment: From the foramen transversarium of the C1 to the foramen magnum.
4. Intracranial/V4 segment.

An abnormal origin of the vertebral artery may favour cerebral disorders because of alterations in cerebral haemodynamics (2) and predispose the patients to intracranial aneurysm formation (3).

Material and Methods

Forty cadavers (37 males; 3 females) were dissected for the study of variations in the origin of the vertebral artery. Deep dissection was done in the head and neck region to expose the vertebral arteries in the scalenovertebral triangle on both the right and the left sides and so, a total of 80 vertebral arteries were exposed. The arteries were explored and their source as well as their mode of origin was ascertained. A real abnormality in origin was encountered in four out of 40 cadavers and all those were on the left side. The course of these abnormal originating arteries was studied in detail and was compared with previous studies by scanning accessible literature. No anomalous origin was seen on the right side.

Results
In one female cadaver, a variant origin of the left vertebral artery from the external carotid artery was encountered. This was found to be a very interesting and extremely rare variant in which a thin and hypoplastic vertebral artery (VA1) with a diameter of 0.9 mm representing the V1 and V2 segment, emanated from the first part of the subclavian artery and entered the foramen transversarium of C6. It was traced in the foramen transversariums of C6 – C4 by cutting their costotransverse bars, but beyond that, it became too thin to be dissected and so, no further attempt was made to trace it in this part. Then, it was dissected in the suboccipital region and it was traced to its source of origin. A dominant vertebral artery (VA2) with a diameter of 3.6mm originated from the external carotid artery in the common with occipital artery at the intervertebral disc between the C2 and C3 vertebrae and took the course of the V3 and V4 segment without entering any foramen transversarium (Table/Fig 1) . The basilar artery was formed by the union of two vertebral arteries, a normal one on the right side and the one of external carotid artery origin on the left side.





In three other male cadavers, the left vertebral artery came from the aortic arch in between the left common carotid and the left subclavian arteries(Table/Fig 2). In one out of these three cadavers, the stem of the left vertebral artery, after taking origin from the aortic arch, was bifurcated into two. One entered C6 and the other into the C5 foramen transversarium (Table/Fig 3). No other associated anomaly of the vascular system or any other system was seen in the study.

Discussion

Though the overall incidence of the anomalous origin of the prevertebral segment of the vertebral artery is low (4), it occurs mostly on one side, usually on the left (5). In our study, all variations in the origin of the vertebral artery that had been encountered, were on the left side. However, a variety of anomalous origins of the vertebral artery on the right side has been reported (Table/Fig 4)describes some important variations of origins of the vertebral artery with their clinical significance as documented in the literature.




On reviewing the literature, it was found that the external carotid artery origin of the left vertebral artery is a very rare variant. It was Flynn(19) who had made mention of such an entity first of all, followed by Matula et al(20). Yilmaz et al (21) performed selective cerebral angiographies in 4400 cases and encountered only one such case (i.e. 0.023%).

Ontogenically, this type of anomaly occurs due to the persistence of the proatlantal intersegmental artery. In early embryonic life (5.3 mm embryo), the primitive trigeminal artery, the primitive otic artery, the primitive hypoglossal artery and the proatlantal intersegmental artery account for important blood supply from the internal carotid arteries to the precursors of the basilar artery. These occur in the form of pairs and are called presegmental arteries. During embryonic development, these usually atrophy, but the persistence of one or the other may lead to carotid-basilar or carotid- vertebral anastomosis (22).

According to Lie (23), in a 5 mm embryo with the atrophy of the primitive hypoglossol artery, the pro-atlantal intersegmental artery supplies blood to the caudal part of the bilateral longitudinal neural artery. In a 12-14 mm embryo, the proatlantal intersegmental artery gradually disappears by forming the intra-cranial part of the vertebral artery. In the case of its persistence, the pro-atlantal intersegmental artery constitutes a carotid-vertebral anastomosis. It originates from the internal carotid artery or the external carotid artery and unites with the horizontal part of the vertebral artery in the suboccipital region (24).

In the present case, it was anastomosis between the external carotid artery and the vertebral artery. Further, it seems that with the persistence of this anastomosis, the V1 and the V2 segments of the vertebral artery proper failed to develop fully haemodynamically and thus, a hypoplastic vertebral artery (V1 and V2 segments) resulted. The main blood supply for the V3 and the V4 segments came through this persistent proatlantal anastomosis between the external carotid artery and the vertebral artery, giving the appearance as if V3 and V4 are arising from the external carotid artery primarily.

In the course of the surgical treatment of certain aneurysms, arteriovenous malformations and carotid cavernous fistulae, the necessity of ligating the common carotid artery or its external or internal branch arises. A ligation of the common carotid artery or the external carotid in cases like this specimen, would definitely result in a serious compromise of the posterior cerebral circulation. So, pre-operative carotid angiography must be done before undertaking such surgeries.

The sole case reported by Yilmaz et al (21), out of 4400 angiographies, had an aneurysm and it was associated with cerebellar ataxia and dysdiadochokinesia. They performed an exhaustive review of the earlier literature on the persistent primitive trigeminal artery, the hypoglossal artery, the otic artery and the proatlantal intersegmental artery and found that most commonly these anastomoses were seen in combination with intracranial vascular anomalies and with cranial nerve symptoms such as trigeminal neuralgia. They also appear to be associated with various neurological diseases such as intracranial tumour, vertebro-basilar insufficiency, multiplesclerosis, subdural haematoma, epilepsy and moyamoya disease.

This led Yilmaz et al (21) to believe that although primitive anastomoses are rarely observed, they may have pathological significance in the development of a variety of intracranial vascular anomalies. So, from the clinical point of view, they recommended that cerebral angiography must be included in the evaluation of patients of any age with unexplained neurological findings.

Among other variants found in the present study, a left vertebral artery of aortic origin between the origins of the left common carotid and the left subclavian artery was encountered in three (7.4%) cadavers. Literature shows the frequency of this anomalous origin to be in the range of 1-5% (25). Argenson et al (13), in their study on 104 cadavers, noted six cases in which the vertebral artery took origin from the aortic arch (5.8%) , all being left sided. However, its incidence is increased manifold (40%) in Down’s syndrome (26).

Embryologically, the vertebral artery is formed between the 32nd and 40th gestational day, from the fusion of the secondary persistent segments of the cervical arteries and the primitive dorsal aortic arch (20). Abnormalities in this fusion process leads to abnormal origins. A left vertebral artery of aortic origin may be because of the persistence of the dorsal division of the left 6th intersegmental artery as the first part of the vertebral artery instead of that of the left 7th dorsal intersegmental artery (4).

A left vertebral artery of aortic origin is found to be associated with a significantly higher incidence of vertebral artery dissection than that of a normal origin (27).

One cadaver was showing bifurcation of the vertebral artery after coming out from the aortic arch. Ontogenically, this condition may be due to the persistence of both precostal and postcostal longitudnal anastomosis. Duplicated vertebral arteries,, because of less diameters, render the risk of vertebral arteriovenous fistula during the injection of the dye for vertebral angiography. Also, since the blood flow is diverted through two channels, it predisposes the patient to vertebrobasilar insufficiency. Moreover, such thin and hypoplastic stems of the vertebral artery are at an increased risk of trauma during surgery of the region, again predisposing the patient to vertebro basilar insufficiency. So, the knowledge of such a condition for a surgeon as well as a physician is indispensable (7).

Without a thorough understanding of the anomalous origins of the great vessels, angiography can be difficult or impossible. If the vertebral arteries are not identified in their normal position, this finding can be misinterpreted as the vessels being congenitally absent. This information is important for vascular or cardiothoracic surgical planning (28). Anomalous origins may lead to altered haemodynamics and may predispose the patient to intracranial aneurysm formation. Therefore, in patients with these anomalies, a thorough search for coexisting aneurysms should be undertaken. Endovascular therapy of intracranial aneurysms can be performed before they present clinically as subarachnoid haemorrhages or mass effect and thereby decrease morbidity and mortality (3).

In this study, we came across a rare anomaly of the left vertebral artery coming from the external carotid artery, which developed due to the persistence of primitive anastomosis, which may have a pathological association with various intracranial anomalies. Therefore, the anatomical arrangement of the major arteries to the brain must be studied before undertaking any surgeries in the head and neck region and in evaluating the patients with neurological pathologies. Secondly, one must be aware of the variations of the vertebral arteries while performing diagnostic and interventional angiography to both identify them correctly and to know where to look when vertebral arteries are not seen in the normal position.

References

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Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE et al.. Cardiovascular system – subclavian system of arteries, In:Gabela G. Edr. Gray’s Anatomy. 38th Edn, New York, London, Churchill Livingstone; 1995: 1529-36.
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Bernardi L and Dettori P. Angiographic study of a rare anomalous origin of vertebral artery. Neuroradiol 1975; 9: 43-47.
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Satti SR, Cernigilia A, Koenigsberg RA. Cervical vertebral artery variations-An anatomical study. Am J Neuroradiol, 2007; 28: 976- 80.
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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 Ind 2002; 51(2): 234-35.
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Rieger P and Huber G. Fenestration and duplicate origin of left vertebral artery in angiography. Neuroradiol 1983; 25: 45-50.
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Daseler EH and Anson BJ. Surgical anatomy of subclavian artery and its branches. Surg Gynaecol Obstet 1959; 108: 149-74.
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Rath G and Parkash R. Double vertebral artery in an Indian cadaver. Anatomia Clinica 1984; 6: 117-19.
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Nogueira TE, Chambers AA, Brueggemeyer MT, Miller TJ. Dual Origin of the Vertebral Artery Mimicking Dissection. Am J Neuroradiol 1997; 18:382-84.
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Wasserman BA, Mikulis DJ, Manzione JV. Origin of the right vertebral artery from left side of the aortic arch proximal to origin of left subclavian artery . Am J Neuroradiol 1992; 13: 355-358.
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Palmer FJ. Origin of right vertebral artery from right common carotid artery. Angiographic demonstration of three cases. Br J Radiol 1977; 50: 185-87.
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Park JK, Kim SH, Kim BS, Chai G . Two cases of aberrant right subclavian artery and right vertebral artery that originated from the right common carotid artery. Korean J Radiol 2008 Jul;9 Suppl:S39-42.
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Strub WM, Leach JL, Tomsick TA. Left Vertebral Artery Origin from the Thyrocervical Trunk: A Unique Vascular Variant Am J Neuroradiol, 2006; 27:1155–56.
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Argenson C, Francke JP, Sylla S, Dintimille H, Papasian S, di Marino V. The vertebral arteries (segment V1 and V2). Anatomia Clinica 1980; 2: 29-41.
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Denkhaus H, Weichert HC, Horn P. Variants der subclavian steal syndrome bei isohert abgehender arteria vertebralis sinistra. Radiologe 1981;21:77-80. Cited by Schwarzacher SW and Krammer EB. Complex anomalies of human aortic arch system: unique case with both vertebral arteries as additional branches of aortic arch. Anat Rec 1989; 225:246-50.
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Albayram S, Gailloud P, Wasserman BA. Bilateral arch origin of the vertebral arteries. Am J Neuroradiol 2002;23:455–58.
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