Efficacy of Endovascular Proximal Occlusion before Direct Reposition Surgery of Blunt Cervical Fracture with Unilateral Vertebral Injury

Diagnosis and management of blunt cerebrovascular injuries: What you need to know

ABSTRACT

Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.

Coil Embolization for Asymptomatic Low-grade Vertebral Artery Injury which Worsened after Cervical Decompression Surgery: A Case Report

Introduction

Blunt cervical injuries rarely cause vertebral artery injuries (VAIs), such as vertebral artery (VA) dissection or occlusion. To prevent subsequent embolic infarction, embolization of the injured VA is needed before surgical fixation of the cervical spine. However, evidence on endovascular treatment for asymptomatic low-grade VAIs with blunt traumatic cervical injury is insufficient.

Case Report

In the present case, a 79-year-old Japanese man presented tetraparesis after falling while walking. Digital subtraction angiography showed no intimal flap and only slight stenosis of the right VA. Embolization was not performed before spinal decompression surgery for this low-grade injury. However, on the 3rd day after surgery, diffuse-weighted imaging showed dot-like high signal intensity in the right thalamus and right posterior lobe, and magnetic resonance angiography (MRA) showed near occlusion of the right VA. 8 days after surgery, MRA showed recanalization of the right VA flow. We performed VA embolization to prevent emboli scattering to the distal region during recanalization of the intracranial blood flow.

Conclusion

According to the relevant literature, prophylactic embolization may be indicated to prevent the embolic infarction not only in cases of VA occlusion requiring fixation of the cervical spine but also in cases of low-grade VAIs in which fixation is not required. Embolization of the VA before spinal surgery might be an aggressive treatment strategy that avoids serious embolic infarction disorder after VAIs.

Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma

PURPOSE

Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO.

METHODS

This study included a total of 241 patients (average age 64.7 years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed.

RESULTS

VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0 months).

CONCLUSION

Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.

Evaluation for Vertebral Artery Injury with Cervical Dislocated Fracture and Optimal Treatment before Reduction

Objective

Cervical dislocated fractures frequently cause vertebral artery injury (VAI), which, in turn, propagates the thrombus at the site of injury. Cerebral embolism due to a thrombus after the reduction of dislocation leads to a poorer neurological outcome. Therefore, we investigated the outcome of treatment for cervical dislocated fractures and the usefulness of parent artery occlusion (PAO) before reduction.

Methods

Eight patients with cervical dislocated fractures with a locked facets treated at our hospital between January 2018 and December 2020 were evaluated. We retrospectively examined patient characteristics and clinical outcomes.

Results

Among the eight patients, two were injured at C4/5, four at C5/6, and two at C6/7. All patients had locked facets. Four patients had bilateral dislocation, while the others had unilateral dislocation. Two patients with unilateral dislocation had ipsilateral vertebral artery occlusion (VAO), while the other six did not. Both patients with VAO underwent PAO to prevent cerebral embolism before reduction. The six patients who did not have VAI underwent reduction without preprocedural treatment. No cerebral ischemic complications were observed. One patient died due to paralysis of the respiratory muscles caused by spinal cord injury but the remaining seven recovered well.

Conclusion

PAO before reduction for cervical dislocated fractures with VAO may be effective in preventing cerebral embolism after reduction.

Interventional Distal Embolization before Corrective Cervical Spinal Surgery for Posttraumatic Vertebral Artery Occlusion: A Case Report and Review of the Literature

Objective

A traumatic vertebral artery (VA) injury may result in serious cerebral infarction in the vertebrobasilar area. However, the approach to its diagnosis and the optimal treatment have not yet been established. We present a patient with traumatic occlusion of a unilateral VA due to the multiple cervical spine fractures who required decompression and fixation, in whom the injured VA was coil embolized distal to the occlusion prior to the cervical spine surgery.

Case Presentation

A 47-year-old woman was injured in a car accident and, presented with C6-C7 superior articular process fractures and C2-C3 ossification of the posterior longitudinal ligament (OPLL) with sensory hypoesthesia and motor palsy of the left upper limb. MRA showed left VA occlusion and patent contralateral VA. DSA showed left VA occlusion from the origin to C5/6 and its antegrade flow by collateral orthodromic circulation from the muscular branches. To prevent vertebrobasilar infarction due to migration of the thrombus from the occluded VA which was recanalized by surgical fixation, distal coil embolization of the injured VA by navigating a microcatheter through the contralateral VA across the vertebrobasilar junction was performed. Neither ischemic events nor new neurologic symptoms occurred during follow-up.

Conclusion

Preoperative coil embolization to a traumatic VA occlusion can be one of the therapeutic choices to prevent thromboembolic stroke after cervical spine surgery. When the proximal segment of the VA was injured and VA occluded from origin, this treatment strategy is feasible, safe, and effective.

Management of Asymptomatic Vertebral Artery Injury Caused by a Cervical Pedicle Screw Malposition: Two Case Reports

Iatrogenic vertebral artery (VA) injury in cervical fusion is an extremely rare complication but can lead to serious sequelae. We present two successful cases of internal trapping for preventing delayed-onset ischemic stroke after iatrogenic VA stenosis caused by a cervical pedicle screw. A 34-year-old female underwent posterior cervical fusion for C4/C5 dislocation fracture. No neurological deficits were observed after the operation. However, the postoperative images revealed that the left C5 pedicle screw perforated the transverse foramen, and the left VA was suspected to be occluded at the screw insertion site. Before revision surgery, we tried to embolize the injured VA with coils. A microcatheter could be navigated from the ipsilateral VA to the distal of the screw, and internal trapping was performed with coils. Another case is that of a 50-year-old male with cervical spondylosis, who underwent posterior decompression and cervical fusion. The neurological symptoms did not deteriorate after the operation. However, the postoperative computed tomography images revealed the perforation of the right C3 transverse foramen by the pedicle screw. In right vertebral angiography, about 70% stenosis was observed at the screw insertion site. Although revision surgery was not planned due to good stability, we embolized the right VA after balloon occlusion test, to prevent the delayed-onset thromboembolic complications. Both the patients recovered without any neurological deficits. Iatrogenic VA injuries, even if asymptomatic immediately after surgery, can lead to serious sequelae in case of delayed-onset ischemic stroke. Therefore, careful attention should be paid when the screw perforates the transverse foramen.