Case report
Iatrogenic perforation of the internal carotid artery by a transarticular screw: An unusual case of repetitive ischemic stroke

https://doi.org/10.1016/j.clineuro.2007.02.008Get rights and content

Abstract

Iatrogenic injury to the carotid artery is an uncommon but well-recognized complication of medical procedures, including cervical spine surgery.

A 60-year-old man showed, over an 8-month period, evidence of recurrent cerebral infarcts in the right carotid artery territory. Repeated cardiovascular screening investigations did not lead towards an etiologic factor.

Three years earlier, the patient underwent an atlantoaxial fixation procedure by means of transarticular screws because of a traumatic subluxation.

An intra-arterial digital substraction angiography showed malpositioning of the fixation screw on the right side with a high grade stenotic lesion of the internal carotid artery and a pseudoaneurysm. The patient was successfully treated with endovascular stenting.

Our case report illustrates the relative importance of iatrogenic carotid injury in the differential diagnosis of stroke after cervical spine surgery.

Introduction

Carotid artery disease is one of the major causes of cerebral ischemia. Iatrogenic injury to the carotid artery is an uncommon but well-recognized complication of diverse medical investigations and interventions. Cervical spine surgery accounts for a small part of the neurosurgical procedures known to cause injury of the carotid artery [1].

In cervical spine surgery, the atlantoaxial transarticular screw fixation technique has been considered the ‘gold standard’ for posterior C1–2 arthrodesis [2]. Direct fixation is a highly effective means of achieving fusion of the atlas and axis with a low complication rate.

However, this procedure requires precise surgical care because serious potential risks of vascular injury can result from improper screw placement [3]. Injury to the vertebral artery by transarticular screws is by far the most frequently reported vascular complication in the literature, but fortunately rarely leads to ischemia of the posterior fossa region [4].

Reports of carotid artery injury with this procedure are very scarce and to our knowledge, there are no reports of cerebral ischemia [5]. Here, we present a case of repeated cerebral infarction due to malpositioning of a transarticular screw, placed 3 years earlier as part of an atlantoaxial fixation procedure.

Section snippets

Case report

A 60-year-old man was admitted to the Hospital Oost Limburg in October 2005 because of an acute weakness and numbness of his left upper limb, an asymmetric nasolabial fold on the same side as well as difficulties with articulation.

Clinical neurological examination revealed a faciobrachial pyramidal paresis and a sensory deficit on the left side.

A consecutive MRI-scan of the brain showed a punctiform, acute ischemic lesion in the middle cerebral artery territory on the right side (Fig. 1, upper

Discussion

We describe a case of recurrent cerebral infarction due to injury of the ICA by a transarticular screw placed 3 years earlier for an atlantoaxial fixation procedure.

ICA injury is a rare complication during or after cervical spine surgery. One case report documents a fatal rupture of the ICA by a motorized drill during anterior screw fixation of an odontoid fracture. Two other reports mention trombosis of the ICA following prolonged retraction for anterior cervical spine surgery [2].

To our

Conclusion

We present an unusual cause of carotid artery injury complicated with repeated cerebral ischemia. Atlantoaxial fixation procedure by means of transarticular screws, is not a rare neurosurgical procedure. Our case illustrates the relative importance of iatrogenic carotid injury in the differential diagnosis of stroke after such a procedure and after cervical spine surgery in general.

Our case underscores that angiography may be a useful investigation in patients with repetitive ischemic stroke of

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