Bartosz Baścik 1, Maksymilian Mielczarek 2, Daniel Ręcławowicz 3, Waldemar Dorniak 1, Tomasz Gorycki 1, Paweł Słoniewski 3, Edyta Szurowska 1
1 2nd Departement of Radiology, Medical University of Gdansk, Gdansk, Poland
2 1st Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
3 Department of Neurosurgery, Medical University of Gdańsk, Gdańsk, Poland
Vertebral artery injury (VAI) may be spontaneous, posttraumatic and iatrogenic. The latter most commonly is a consequence of cervical spine surgery. VAI encompasses wall dissection, but also wall perforation with overt hemorrhage as well as arteriovenous fistula (AVF) and pseudoaneurysm (PA) formation.
We present a 30-year old male patient, in whom massive bleeding from the right vertebral artery (VA) occurred during surgery for posttraumatic bilateral interfacet dislocation (BIT) of C4-C5. Immediately bleeding was managed by packing with subsequent transfer to the Interventional Radiology Department. On site, bilateral arterial femoral access was achieved with 6F introducer sheaths. Simultaneous digital subtractive angiography (DSA) of VAs was performed. VAs were of similar size and contributed equally to basilar artery (BA) inflow. DSA revealed the site of active bleeding within V2 segment of the right VA. Because of uncontrolled blood extravasation coil embolization of the VA was conducted. A microcatheter with a guidewire was advanced into the right VA, above the bleeding site. Retrograde embolization was conducted using detachable coils. Embolization was controlled with stepwise microangiography to prevent inadvertent occlusion of spinal branches. Finally, DSA of the contralateral VA showed adequate perfusion of posterior fossa via the BA and the posterior inferior cerebellar artery over vertebro-basilar junction. Bilateral DSA of internal carotid arteries revealed effective collateral inflow via posterior communicating arteries. Subsequently, the patient was transferred back to the operating theater, where fusion of C3-C5 was finalized. There was no neural sequelae, however, postoperative period was complicated with laryngeal oedema, requiring corticosteroids therapy.
Overt bleeding from the VA requires urgent action to inhibit blood leakage. Packing shouldn’t be considered a definitive treatment strategy. Definitive treatment strategies may be grouped into reconstructive or deconstructive. It’s of utmost importance, that any decision with regard to definitive treatment strategy should be made after comprehensive assessment of posterior fossa vasculature, which could be solely provided by DSA. If contralateral VA adequately supplied BA inflow, usually deconstructive approach would prevail due to its rapidity. With advances in interventional therapy, the role of endovascular treatment of VAI, as in the herein case, will continue to increase.