Bilateral vertebral artery dissecting aneurysm with subarachnoid hemorrhage treated with staged bilateral vertebral artery coil occlusion: a case report

BACKGROUND: Vertebral artery dissecting aneurysm is now increasingly recognized as a cause of posterior circulation stroke in young adults. Here, we report a case of bilateral VADA with SAH, treated by bilateral coil occlusion using GDCs. CASE DESCRIPTION: A 64-year-old woman was admitted to our hospital with consciousness disturbance (Hunt and Kosnik: grade 4). Computed tomography showed diffuse SAH with a thick hematoma in the left C-P angle. Magnetic resonance angiography, 3D-CTA, and cerebral angiography revealed bilateral VADAs. First, the ruptured left VADA involving the PICA and a perforating branch was treated by occluding the lower half of the VADA and the proximal VA with GDCs in the acute stage. Thereafter, the residual VADA and contralateral VADA exhibited enlargement on cerebral angiography and MRA for 2 months after the initial surgery; thus, the right VADA was occluded by GDCs just proximal to the right PICA after confirming BTO tolerance. CONCLUSION: Staged bilateral VA coil occlusions combined with BTO may be one of the treatment strategies for bilateral VADA with SAH in cases presenting surgical difficulty due to anatomical factors or severe grade of SAH.     

Simultaneous bilateral vertebral artery occlusion in the lower cervical spine manifesting as bow hunter's syndrome

A 59-year-old male had suffered near-syncopal episodes for more than one year that occurred immediately on turning his head to the left. Cerebral magnetic resonance (MR) imaging did not detect any contributing lesions with well-developed posterior communicating arteries. Dynamic radiography of the cervical spine showed mild instability at C5-6 and concomitant intramedullary hyperintensity confirmed by T(2)-weighted MR imaging. Cervical computed tomography demonstrated an osseous protrusion in the right foramen transversarium at C5. Dynamic cerebral angiography revealed simultaneous vertebral artery (VA) occlusion at C6 on the right and C5 on the left associated with leftward head rotation. The VA showed an intact course at the C1 to C2 levels. The patient underwent anterior fusion followed by decompressive foraminotomy at C5-6 and C6-7 and meticulous resection of the markedly thickened fibroligamentous structure which was considered to contribute to the rotational VA occlusion. Postoperatively he no longer suffered near-syncope during head rotation. Bow hunter's syndrome is an infrequent type of vertebrobasilar insufficiency that may need surgical management for potential threat of ischemic stroke. Simultaneous VA occlusion at the lower cervical level can cause bow hunter's syndrome. Dynamic cerebral angiography is a useful modality for evaluating bow hunter's syndrome even if the patient cannot tolerate dynamic examination for the immediate symptom. Accurate anatomical knowledge of the uncovertebral foraminal region combined with intraoperative dynamic study is essential for safe surgery to the VA and favorable outcome.     

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN: A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. OBJECTIVES: To determine the clinical and radiologic features of vertebral artery injury. SUMMARY OF BACKGROUND DATA: Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. METHODS: Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. RESULTS: The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. CONCLUSIONS: Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.     

颈椎不稳在椎动脉型颈椎病发病中的意义

椎动脉型颈椎病是中老年颈椎病患者中最常见的类型,长期以来医学界对其发病机制认识不统一,因此导致此病命名各异,如颈性眩晕,Barre—Lieou综合征,椎一基底动脉缺血综合征,颈交感神经综合征等。门诊经常见到眩晕的患者经多科室诊治仍不能确诊,即使诊为椎动脉型颈椎病,也给予扩血管药物、中药、制动、理疗、牵引等保守治疗,使得症状反复发作,给患者带来极大痛苦和精神压力。将其他型颈椎病合并有头痛、眩晕,旋颈试验阳性,有猝倒病史的患者进行手术治疗,疗效满意,现将结果报告如下。     

Occlusion of the vertebral artery in cervical spine dislocations

We studied 12 consecutive patients with facet joint dislocation in the cervical spine to assess the incidence, site and clinical sequelae of occlusion of the extracranial vertebral artery. Intra-arterial digital subtraction angiography was performed after the orthopaedic management of the dislocations. This demonstrated vertebral artery occlusion (one bilateral) in five of the seven patients with bilateral dislocations and in four of the five patients with unilateral dislocations. Two of the nine patients with vertebral artery occlusion had neurological deficits above the level of the injury, all of which resolved spontaneously within two months. In our experience, a distraction-flexion injury appears to be the most common cause of closed traumatic vertebral artery occlusion.     

Lateral cervical spine dislocation and vertebral artery injury.

Although anterior and posterior traumatic displacement of cervical vertebrae are commonly noted, and the devastating neurological deficits associated with these injuries have been amply defined, lateral displacement with fractures has been rarely recognized, and the clinical significance of this injury has been overlooked. This report describes five cases of cervical spine fractures with lateral dislocation. All patients had lateral and anteroposterior cervical spine radiographs as well as cervical angiography or postmortem study demonstrating either complete occlusion or significant impairment of flow of the vertebral arteries. Two cases had traumatic vertebral artery occlusion with secondary medullary and cerebellar infarction resulting in the patient's death. Vertebral artery injury apparently is not uncommon in this particular type of fracture. The diagnosis of these vascular injuries may require angiography or magnetic resonance angiography. A vertebral occlusion or dissection is a problem of considerable complexity, requiring individualized management depending on the patient's symptomatology, location and nature of the injury, and time lapsed since the injury.     

Iatrogenic vertebral artery injury during anterior cervical spine surgery.

BACKGROUND CONTEXT: Iatrogenic injury to the vertebral artery during an anterior cervical decompression is a rarely mentioned but potentially catastrophic complication. PURPOSE: This study was designed to examine the incidence and management of iatrogenic vertebral artery injury (IVAI) in a large database. STUDY DESIGN/SETTING: This was a retrospective study performed at a large teaching institution over a 7-year period (1994-2001). PATIENT SAMPLE: All anterior cervical spinal procedures performed for herniated or degenerative disc disease, or cervical spondylosis were identified, as were incidences of IVAI. Anterior cervical procedures performed for trauma, neoplasia, or infection were excluded from this study. OUTCOME MEASURES: Neurological and associated morbidity as well as mortality were recorded. METHODS: Data were accessed through an institution-wide electronic medical record search through the operative reports of 10 spine surgeons. Hospital and clinical charts of IVAI cases were subsequently reviewed. Demographic data and intraoperative strategies for repair were recorded. RESULTS: A total of 1,976 patients underwent anterior cervical spinal procedures in the review period. Six cases of IVAI were identified. In three of the six patients, arterial bleeding was controlled with hemostatic agents. Of these three, two suffered complications. The initial management of controlling arterial bleeding is by hemostatic agents; however, one must also consider repair or ligation. The remaining three patients were treated with primary repair or ligation, and no complications were noted. CONCLUSIONS: IVAI is a rare complication (0.3%) of anterior cervical procedures. The arterial bleeding can usually be controlled with topical hemostatic agents, but mortality may occur in instances where it cannot be adequately addressed in a timely fashion.     

Closed cervical spine trauma associated with bilateral vertebral artery injuries

Bilateral vertebral artery injuries in closed cervical spine injuries are uncommon, but early recognition and treatment are important to prevent neurological deterioration. A case of bilateral vertebral injuries in a 35-year-old motor vehicle accident victim is presented, and the current literature is reviewed.     

颈椎手术中并发椎动脉损伤的诊断与治疗

 目的 探讨颈椎手术中并发椎动脉损伤的发生原因、治疗及预防。方法 回顾性分析2002年10月至2012年4月颈椎手术中并发椎动脉损伤的7例患者资料,男6例,女1例;年龄23～65岁,平均48.9岁;脊髓型颈椎病5例,颈椎外伤合并C^4,5半脱位1例,氟骨症致颈椎管狭窄1例。椎动脉损伤均为单侧,左侧4例,右侧3例。分析颈椎手术中并发椎动脉损伤的原因、处理过程及预后。结果颈椎前路手术4例,其中2例用环钻减压时偏离中线损伤椎动脉,1例切除椎间盘时刮匙过于偏外损伤椎动脉,1例颈椎外伤患者由于Ｃ^4,5半脱位造成椎动脉迂曲,减压时冲击式咬骨钳损伤椎动脉。颈椎后路手术3例,其中2例为行C4侧块螺钉固定时钻头偏外损伤椎动脉;1例氟骨症致颈椎管狭窄者在切除寰椎后弓时咬骨钳损伤椎动脉,术中出现椎动脉损伤后,迅速填塞压迫止血并关闭伤口,但术后4周发生迟发性出血,采用椎动脉栓塞止血及颈后路血肿清除术治疗。7例患者均未发生脑梗塞,其中2例患者术后出现一过性头晕。结论 椎动脉损伤是颈椎手术的严重并发症,其损伤原因与手术失误、解剖变异等有关;采用直接压迫及椎动脉栓塞治疗效果确切。     

正常椎动脉解剖特点及其变异概况

椎动脉由锁骨下动脉发出,左右各一,穿过颈椎体侧方第6～第1横突孔,经枕骨大孔上升到颅内后行于延髓腹侧,两条椎动脉在脑桥下缘汇合在一起,形成一条粗大的基底动脉,即通常所称的椎-基底动脉系统。椎-基底动脉系统是脑血液供应的重要组成部分,分布于脑干（延髓到间脑尾侧1/3）、大脑半球的后1/3（包括部分颞叶、枕叶和小脑）。椎动脉与颈椎有着密切的关系,颈椎的横突孔保护着椎动脉,但颈椎的的病损也可以危及椎动脉。随着颈椎外科和内固定技术的发展,手术操作或内置物置入过程损伤椎动脉是椎动脉损伤的常见原因之一[1～3],尤其在椎动脉有变异的情况下,损伤的几率会明显增加。     

Traumatic rupture of the vertebral artery associated with fracture of the cervical spine: a case report

We report here a case of traumatic rupture of the vertebral artery associated with fracture of the cervical spine. A 72-year-old woman was found at the bottom of the stairs by her family. She was immediately transferred to our hospital. She was, in spite of being in a state of shock, alert and oriented with normal respiration. A curvilinear laceration at the right suboccipital region was noticed. On neurological examination, she was diagnosed as having tetraparesis. Roentgenograms confirmed fractures of a vertebral body at C 6 and a transverse process at C 7. Head CT scan demonstrated a small low density area in the left putaminal region with cortical atrophy. As subcutaneous swelling of the left lower cervical portion was gradually taking place, vertebral arteriography was performed. Through left vertebral arteriography, extravasation of the contrast medium was demonstrated at the C6-7 level. Eighteen hours after admission, direct operation on the torn vessel was carried out through a supraclavicular linear skin incision. On operation, there was active bleeding from the lacerated vertebral artery at its point of entrance into the foramen transversarium. The bleeding point of the vertebral artery was trapped at the C 6 level. Postoperatively, the symptoms of the tetraparesis were improving. Two days after the operation, she had some food by herself. Suddenly, she had cardiac arrest five days after admission, and soon expired. It was 13 days since she had been admitted. Traumatic tear of a vertebral artery is very rare. Fourteen cases of intra-and extracranial vertebral artery rupture in closed head injury have been reported in previous writings.(ABSTRACT TRUNCATED AT 250 WORDS)     

Unilateral postoperative visual loss due to central retinal artery occlusion following cervical spine surgery in prone position

Postoperative visual loss following spinal surgery is a rare complication. Although a number of intraoperative and postoperative factors have been implicated exact etiology still may remain unclear. We report a case of unilateral postoperative visual loss in a patient who had undergone prolonged spine surgery in a prone position.     

Masking of vertebral artery dissection by severe trauma to the cervical spine

STUDY DESIGN: A prospective case study was performed. OBJECTIVES: To illustrate the association of cervical trauma with vertebral artery dissection, and to propose a diagnostic and therapeutic algorithm for suspected traumatic vertebral artery dissection. SUMMARY OF BACKGROUND DATA: Vertebral artery dissection is a recognized but underdiagnosed complication of trauma to the cervical spine. Symptoms of spinal cord injury, however, may obscure those of vertebral artery dissection, presumably causing gross underdiagnosis of this complication. METHODS: All patients with vertebral artery dissection admitted to the authors' facility between 1992 and 1997 were screened for cervical trauma. RESULTS: This article presents four patients with severe trauma to the cervical spine, defined as luxation, subluxation, or fracture, in whom symptoms of vertebral artery dissection developed after a delay ranging from several hours to weeks. The traumatic vertebral artery dissection typically was located at the site of vertebral injury or cranial to it. One patient with fracture of the odontoid process survived symptom free without ischemic brain infarctions. Another patient survived with traumatic quadriplegia in addition to large cerebellar and posterior cerebral artery infarctions. Two patients died as a result of fulminant vertebrobasilar infarctions, both with only moderate impairment from the primary spinal cord injury. CONCLUSIONS: Early signs of vertebral artery dissection include head and neck pain, often localized to the site of intimal disruption, which may be disguised by the signs of the spinal injury. Early Doppler ultrasound and duplex sonography as a noninvasive screening method should be performed for patients with severe trauma to the cervical spine. In cases of vertebral artery dissection, immediate anticoagulation should be initiated. Traumatologists should be aware of this complication in evaluating patients with severe trauma of the cervical spine, and also for a variety of forensic reasons.     

Esophageal and vertebral artery injuries during complex cervical spine surgery--avoidance and management

Vertebral artery and esophageal injuries are rare but feared complications of cervical spine surgery. Appropriate understanding of treatment algorithms for prompt intervention in the event of a vertebral artery injury minimizes the risk of exsanguination and/or profound neurologic consequences. Esophageal injuries are often more subtle, and although intraoperative injuries can sometimes be diagnosed at the time of surgery, they frequently do not present until the week after surgery. They can additionally be seen as a late complication of instrumentation usage and/or failure. Expedient diagnosis and management of these injuries minimize their impact and allow for optimal treatment outcome.