Name:
FOCUS25824video1
Description:
FOCUS25824video1
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/21550fec-c69e-4d41-b444-4c1f7fa9ff6a/videoscrubberimages/Scrubber_0.jpg?sv=2019-02-02&sr=c&sig=LbZ4hMHDqvYhjoCa%2B1kRJB6ti%2F3GNyEM2jzQZ%2BlGzaM%3D&st=2026-04-05T07%3A51%3A53Z&se=2026-04-05T11%3A56%3A53Z&sp=r
Duration:
T00H05M50S
Embed URL:
https://stream.cadmore.media/player/21550fec-c69e-4d41-b444-4c1f7fa9ff6a
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/21550fec-c69e-4d41-b444-4c1f7fa9ff6a/1. 25-30.mp4?sv=2019-02-02&sr=c&sig=od8E%2FkVgKc3hmHsTkXqy0T79fyznaXgp5yzeiRU6vzA%3D&st=2026-04-05T07%3A51%3A53Z&se=2026-04-05T09%3A56%3A53Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: We present the case of a 3-year-old male
SPEAKER: with developmental delay, who presented with worsening myelopathy and brainstem dysfunction, including dysphagia. On evaluation, the child was unable to hold his head up. One year prior to this presentation, he underwent wide decompression, including C1–4 laminectomy for a Chiari malformation. Since then, he developed significant upper cervical kyphotic deformity and instability at the craniocervical junction.
SPEAKER: This initial MRI taken post–Chiari decompression shows narrowing of the upper cervical canal from the craniocervical junction to C4 with mild cord flattening. A CT was taken 5 months later, which demonstrated slight interval worsening of upper cervical kyphosis and a stable anterolisthesis of C2 on C3. Stable central canal narrowing was also shown, particularly at the C3–4 level.
SPEAKER: As a result of these findings and clinical presentation, it was felt that the patient would benefit from posterior fixation and fusion from the occiput to T2 to correct his deformity and prevent further neurologic decline. The surgery was performed with intraoperative monitoring and image guidance. During cannulation of the left C1 lateral mass, a small arterial blush was noted.
SPEAKER: This bleeding was easily controlled by completing screw placement and packing bone wax around the screw. No Surgifoam or other prothrombotic agents were required as the bleeding stopped immediately. Circumferential dissection around C1 also failed to demonstrate any hematoma or active bleeding. During this period, the patient experienced transient hypertension and bradycardia, with a brief reduction in the left upper somatosensory evoked potential signal.
SPEAKER: These changes quickly normalized with elevation of the patient's blood pressure. Rods and a structural fibular allograft were placed and secured, and the case was terminated immediately. Postoperative x-ray showed improved alignment and correction of preoperative upper cervical kyphosis. Given the concern for vascular injury, a CT angiogram was also obtained immediately postoperatively. It demonstrated occlusion of the patient's dominant left vertebral artery from C2 to the level of the basilar artery.
SPEAKER: No retrograde flow into the occluded vessel or left posterior inferior cerebellar artery was seen. Subarachnoid hemorrhage was also present within the basilar cisterns. Subsequent catheter angiography demonstrated a dissection of the left vertebral artery and a small pseudoaneurysm at the vertebral basilar junction. Follow-up angiography several days later showed enlargement of the pseudoaneurysm.
SPEAKER: Therefore, the aneurysm was treated with coil embolization. However, the aneurysm ruptured during the embolization procedure. The child ended up with infarcts throughout the pons, midbrain, and bilateral thalami, furthering neurologic compromise from his already poor baseline. Initial exam showed GCS 5T. The patient also required an EVD and feeding tube and had a prolonged ICU course.
SPEAKER: He was discharged home on POD 35, with the exam indicating GCS 8 and pupils still nonreactive. At 19 months, the patient's status showed no improvement. He remained trach and feeding tube dependent and developed a seizure disorder. The patient never recovered and passed away a few years after. Overall, vertebral artery injuries are a rare but devastating complication when working around the craniocervical junction, with an incidence ranging from 0.08% to 1.4% in the literature, depending on approach.
SPEAKER: At all points in this case, image guidance accuracy was confirmed by touching normal landmarks, and there was no appreciable shift that would be of concern for loss of fidelity. We believe that cannulation of the lateral mass with a small cortical breech may have caused traction and wrapping of the vertebral artery, leading to the dissection and subsequent distal aneurysm formation.
SPEAKER: This breach may have occurred due to deflection of the drill tip and cartilaginous bone. One potential solution is to use an image-guided small-bore tap instead of drilling along the expected trajectory with an image-guided drill, as the former allows for more freehand control. As in this case, the appropriate next step when arterial bleeding is encountered during cannulation is to place the screw, which can help tamponade the bleed.
SPEAKER: If vascular injury is suspected, the contralateral screw should be abandoned to prevent a bilateral injury, which can be fatal. Diagnostic testing with CTA and catheter angiography should be done immediately. In this case, we quickly placed the rods, locked down the screws, and closed for prompt evaluation of the extent of injury. However, avoidance of this injury remains the priority.
Form Title Download
Form Title Bookmark
Form Title Share
Form Title Cite
