Vertebral artery complications in anterior approaches to the cervical spine: report of two cases and review of literature

BACKGROUND: Cases of lesions to either the carotid artery or the vertebral artery in anterior approaches to the cervical spine are rarely found in medical literature. Two cases of vertebral artery injury in anterior approaches as well as a review of the pertinent literature are presented. In cases of arterial injury, appropriate management strategies are necessary to avoid or minimize harm to the patient. CASE REPORTS: In the first case, the vertebral artery was injured during decompression of a cervical spinal stenosis while drilling the neuroforamen. Local compression provided sufficient control of hemorrhage. Nevertheless, rebleeding from a pseudoaneurysm occurred 2 days later. After removal of the hematoma, the pseudoaneurysm was treated successfully with coils by an endovascular approach. In the second case, misplacement of one screw in screw-fixation of a type II odontoid fracture caused a pseudoaneurysm of the vertebral artery. This led to a fatal subarachnoid hemorrhage 4 days later. CONCLUSIONS: In ventral approaches to the cervical spine, precise preoperative planning and a detailed knowledge of the surgical anatomy are mandatory. In cases of injury to the vertebral arteries, direct surgical repair is most appropriate to prevent complications arising from fistulas, late-onset hemorrhages, pseudoaneurysms, thrombosis, and emboli. Alternatively, endovascular techniques or even clipping or ligation of the affected artery should be considered.     

Delayed treatment of a traumatic left subclavian artery pseudoaneurysm

A 22-year-old man sustained 4 gunshot wounds to the upper torso resulting in left pneumothorax, an expanding right neck hematoma, left humerus fracture, a traumatic arteriovenous fistula from the right subclavian artery to the right brachiocephalic vein, and pseudoaneurysm formation from partial transection of the right subclavian artery. The patient underwent emergent repair of the confluence of the right internal jugular, subclavian and brachiocephalic veins, and laparotomy secondary to compartment syndrome. Seven weeks later, with the pseudoaneurysm enlarged to 6 cm, it was repaired with combined access via the right common femoral artery and right brachial artery. The pseudoaneurysm was covered with a 7 mm x 8 cm fluency-covered stent graft and postdilated with a 7 mm x 4 cm balloon. Postoperatively, the patient had palpable pulses, occlusion of the pseudoaneurysm, and excellent blood flow into the arm.     

Isolated Traumatic Vertebral Pseudoaneurysm: Report of a Case

We report a case of isolated traumatic pseudoaneurysm of the vertebral artery in a 20-year-old man who suffered blunt injury to the left foreneck and arm in a traffic accident. A chest computed tomography (CT) scan on admission showed an upper mediastinal hematoma, but the patient's vital signs were stable. A CT scan of the head and neck showed a cerebral mass, and an elective cerebral four-vessel angiography was performed, whitch revealed a pseudoaneurysm in the proximal portion of the left vertebral artery. At surgery, about 2 cm of the left vertebral artery was found to be lacerated, and suture ligation was done on each side of the laceration. Postoperative intravenous digital subtraction angiography showed an intact right vertebral artery with no residual pseudoaneurysm. There were no neurological complications and the patient was discharged on the 16th postoperative day. Received: December 13, 2001 / Accepted: July 2, 2002 Reprint requests to: T. Saito     

Giant pseudoaneurysm of the extracranial vertebral artery successfully treated using intraoperative balloon catheters.

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.     

Traumatic vertebro-vertebral arteriovenous fistula manifesting as radiculopathy. Case report

A 58-year-old man presented with a traumatic vertebro-vertebral arteriovenous fistula (VVAVF) after attempting suicide by thrusting scissors into his right anterior cervical region. Two months later he noticed weakness and numbness of the right upper extremity. Examination revealed bruit in the right neck, no cranial nerve palsy, and weakness of the right deltoid and biceps muscles. Hypalgesia and hypesthesia were noted in the right C5 and C6 dermatomes. Magnetic resonance imaging demonstrated a mass lesion on the right ventral aspect of the spinal canal from C2 to C7. Right vertebral artery angiography showed a pseudoaneurysm of the right vertebral artery and a high-flow arteriovenous fistula between the right vertebral artery and vein. The right vertebral artery was occluded with detachable coils because the fistula showed high blood flow and the right posterior inferior cerebellar artery was well opacified from the left vertebral artery. This procedure resulted in complete obliteration of the arteriovenous fistula. The preoperative motor and sensory symptoms improved. Endovascular treatment by coil embolization was effective in our patient with traumatic VVAVF.     

Combination of stenting and coil embolization for carotid artery pseudoaneurysm causing symptomatic mass effect: case report

A case of cervical pseudoaneurysm secondary to carotid artery dissection causing symptomatic mass effect was reported. A 60-year-old woman presented with the complaint of right neck swelling and dysphagia that was considered to be the mass effect of a pseudoaneurysm caused by dissection of the right common carotid artery (CCA). Although a self-expanding stent was deployed to cover the orifice of the pseudoaneurysm, the pseudoaneurysm had been enlarged because of thrombus formation on the inner wall. A microcatheter was guided through the stent mesh into the aneurysm, and Guglielmi detachable coils were placed to embolize the orifice. One month later, angiography revealed complete embolization of the aneurysm while preserving flow in the CCA. The mass effect attributable to the pseudoaneurysm was relieved symptomatically as well as radiologically. Carotid artery dissection with symptomatic mass effect can be treated successfully, using a combination of stent and coils. This method may be considered to be an alternative to conventional surgical treatment such as proximal ligation, extracranial-intracranial bypass, or direct surgical repair.     

Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report

BACKGROUND: Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described. CASE DESCRIPTION: A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence. CONCLUSIONS: Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.     

Vertebral artery pseudoaneurysm. A rare complication of subclavian artery catheterization

The present case report details a previously unreported complication of subclavian vein catheterization, vertebral artery pseudoaneurysm. Attention to this problem was brought about in the patient by the development of stridor and dysphagia noted 5 days following placement of the subclavian catheter. A computed tomographic scan of the neck revealed a superior mediastinal, contrast-enhancing mass in the region of the right subclavian artery with a "bull's-eye" sign suggestive of a pseudoaneurysm. Arteriography subsequently proved the pseudoaneurysm to be of vertebral origin. The pseudoaneurysm was ligated via a neck incision together with a median sternotomy to obtain vascular control. The evaluation and treatment options of this problem are discussed.     

Pseudoaneurysm of the extracranial vertebral artery; a case report

Traumatic injury of the vertebral artery is rare and only a few reports have been presented. We treated a case of iatrogenic pseudoaneurysm of the extracranial vertebral artery. A 65-year-old man complained of headache and had a pulsating mass in the soft tissue of the neck which had continued for one month after evacuation of hypertensive cerebellar hemorrhage. The left VAG revealed a large pseudoaneurysm at the third portion of the vertebral artery and the right retrograde VAG revealed agenesis of the vertebral artery. To select the proper treatment was a dilemma. This case was treated by embolization using an occluding spring embolus with direct transcutaneous puncture of pseudoaneurysm. Following this treatment, the mass and associated symptoms resolved without neurological deficit.     

Cervical vessel injury after blunt trauma

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.     

Blunt traumatic superior gluteal artery pseudoaneurysm presenting as glutealhematoma without bony injury: A rare case report

Blunt traumatic injuries to the superior gluteal artery are rare in clinic. A majority of injuries present as aneurysms following penetrating trauma, fracture pelvis or posterior dislocation of the hip joint. We reported a rare case of superior gluteal artery pseudoaneurysm following blunt trauma presenting as large expanding right gluteal hematoma without any bony injury. The gluteal hematoma was suspected clinically, confirmed by ultrasound and the arterial injury was diagnosed by CT angiography that revealed a large right gluteal hematoma with a focal contrast leakage forming a pseudoaneurysm within the hematoma. Pseudoaneurysm arose from the superior gluteal branch of right internal iliac artery, which was successfully angioembolized. The patient was discharged on day 4 of hospitalization with resolving gluteal hematoma. This report highlighted the importance of considering an arterial injury following blunt trauma to the buttocks with subsequent painful swelling. Acknowledgment of this rare injury pattern was necessary to facilitate rapid diagnosis and appropriate treatment.     

Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation: case report

BACKGROUND: Vertebral artery injury during posterior C1-2 transarticular screw fixation occurs in approximately 3% of patients and may remain asymptomatic or result in arteriovenous fistulae, occlusion, narrowing, or dissection of the vertebral artery, and lead to transient ischemic attacks, stroke, or death. CASE DESCRIPTION: This is the first report of a pseudoaneurysm resulting from damage to the vertebral artery during the procedure. This 31-year-old male underwent posterior C1-2 transarticular screw fixation for unstable os odontoideum. Injury to the left vertebral artery occurred while the hole for the left screw was being drilled. Temporary control of bleeding with local pressure was followed by immediate postoperative angiography that revealed a left vertebral artery pseudoaneurysm. Although the patient remained asymptomatic, therapeutic anticoagulation was instituted 6 hours postoperatively. Increasing size of the pseudoaneurysm was noted on routine follow-up angiography 4 weeks later. Endovascular occlusion of the pseudoaneurysm and left vertebral artery, with preservation of vertebrobasilar flow through the right vertebral artery, was accomplished without neurological consequence. CONCLUSIONS: Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation may be effectively treated with endovascular approaches.     

Proximal ligation of the parent artery for symptomatic tandem stenosis of the extradural internal carotid artery: a case report

A 72-year-old man suffered blindness due to right central retinal artery occlusion. Cerebral angiography revealed tandem stenosis in the cervical, petrosal and cavernous portions of the right internal carotid artery (ICA). Blood flow from the vertebrobasilar artery via the right posterior communicating artery mainly perfused the right cerebral hemisphere. In addition, significant stenosis was observed in the left cervical carotid artery and the origin of the left vertebral artety. First, the patient underwent left carotid endarterectomy and vertebral artery to subclavian artery transposition. Two months later, ligation of the right ICA at its origin was performed. Postoperative course was uneventful and the patient has not experienced further ischemic events. We suggest that proximal ligation of the parent artery is a useful procedure for medically-refractory extradural ICA stenosis when surgical direct revascularization and percutaneous transluminal angioplasty cannot be performed.     

Cervical root compression by a traumatic pseudoaneurysm of the vertebral artery: case report

We report the case of a patient with cervical monoradiculopathy secondary to a pseudoaneurysm of the vertebral artery caused by a knife wound to the neck.     

Occipital artery to extradural vertebral artery bypass procedure. Case report

A 17-year-old boy suffered blunt trauma to the posterior cervical spine and later developed vertebrobasilar transient ischemic attacks refractory to medical management. At angiography, a pseudoaneurysm of the distal left vertebral artery was found. By means of a posterior midline approach, an extradural occipital artery to vertebral artery anastomosis was performed and the affected vertebral artery was clipped distal to the pseudoaneurysm. The indications for this procedure, the operative approach, and the clinical outcome are described.     

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。     

Vertebral arteriovenous fistulae. Report of two cases and review of the literature

Summary Two patients with vertebral arteriovenous fistulae were treated at the Neurosurgical Clinic of the City Hospital of Hannover between 1981 and 1988. Both patients were males, 19 and 29 year old. The fistulae were secondary to cervical gunshot wounds. Both patients complained of a loud cephalic noise; 1 patient had a non pulsating neck mass. A systolic cervical bruit was heard in both cases. One patient had an incomplete mid-cervical Brown-Sequard syndrome. The fistulae involved the second portion of the vertebral artery; 1 fistula was fed, in addition to the vertebral artery, by the deep cervical artery. Venous drainage was through intraspinal plexus, vertebral vein, deep cervical veins and internal jugular vein. One patient was treated with a direct surgical trapping of the vertebral artery proximal and distal to the fistula; the other patient, in addition to direct surgical vertebral artery trapping, received an endovascular balloon occlusion of the deep cervical artery. After treatment the fistulae disappeared, both clinically and angiographically.Dr. Mario Ammirati is a recipient of a fellowship from the Alexander von Humboldt Foundation, Bonn, FRG.     

Pseudoaneurysm of the Cystic Artery Secondary to Cholecystitis as a Cause of Hemobilia: Report of a Case

Spontaneous intracholecystic bleeding is very rare. We report herein a very rare case of a pseudoaneurysm of the cystic artery due to acute cholecystitis. A 58-year-old man presented at the emergency department complaining of colicky pain in the right upper quadrant. Dynamic magnetic resonance imaging demonstrated an early-enhanced pooling of contrast material (suggestive of a pseudoaneurysm of the cystic artery) inside the neck of the gallbladder. After the proximal control of the hepatic artery, the patient underwent a cholecystectomy and a ligation of the cystic artery. The resected specimen of the gallbladder showed evidence of a massive intracholecystic hematoma. Proximal to the impacted gallstone in the neck, a 2-cm diameter saccular-type pseudoaneurysm was identified. Although a pseudoaneurysm of the cystic artery is very rare, it should be included in the differential diagnosis of hemobilia. Once the pseudoaneurysm is confirmed, its embolization before a cholecystectomy (which can be attempted laparoscopically) may be useful to ensure the safety of the patient.     

Direct surgery for posttraumatic carotid-cavernous fistula as a result of an intradural pseudoaneurysm: case report

OBJECTIVE AND IMPORTANCE: Traumatic carotid-cavernous fistula (CCF) is currently treated with interventional neuroradiological embolization procedures. A rare case of posttraumatic CCF that resulted from an intradural pseudoaneurysm is presented. The patient was treated by direct surgery because an embolization procedure was not suitable. CLINICAL PRESENTATION: A 16-year-old boy developed chemosis in the right eye 17 days after a traffic accident. Angiography revealed a pseudoaneurysm that arose from the site of origin of the posterior communicating artery, drained directly into the cavernous sinus, and formed a high-flow CCF. INTERVENTION: Direct surgery was performed to repair the arterial laceration at the junction of the internal carotid artery and the posterior communicating artery. A clip was applied along the internal carotid artery. The posterior stump of the damaged posterior communicating artery was also included in the clip. Postoperatively, the CCF and pseudoaneurysm were completely obliterated, and the symptoms were cured. CONCLUSION: Awareness of an unusual intradural origin of a CCF and the possibility of a direct surgical treatment should be kept in mind.     

Acute subdural hematoma and death following lateral cervical spinal puncture. Case report

An acute subdural hematoma dissecting into the posterior cranial fossa and resulting in death is reported. The patient had undergone spinal puncture by the lateral cervical technique prior to development of the hematoma. Autopsy demonstrated that the source of hemorrhage was an anomalous intraspinal vertebral artery.