Introduction: Management of vertebral artery occlusion in a patient with cervical fracture dislocation is unclear. There is a possibility of dislodgement of an unstable thrombus during fracture reduction if the artery is mechanically kinked causing the occlusion.
Methods: We describe a case of a devastating complication of fracture reduction and review our early experience with prophylactic vertebral artery stump occlusion to prevent thrombus dislodgement during fracture reduction.
Results: One patient with a C4-5 fracture-dislocation was identified with an ASIA A spinal cord injury and unilateral vertebral artery occlusion (figure 1). Preoperatively, there was no evidence of stroke. Post reduction and fusion, the patient suffered extensive posterior circulation strokes, requiring suboccipital decompression. A CTA showed partial recanalization of the occluded segment (figure 2). Three patients were identified with similar clinical histories (fracture dislocation, unilateral vertebral occlusion, and no evidence of initial stroke) who were treated by deploying a newly released vascular occlusion device (Microvascular Plug MVP: Medtronic: Dublin Ireland) into the vertebral stump to stabilize the occluded segment either immediately before reduction (2 cases) or immediately after reduction (1 case). (See figure 3) The procedure was technically successful in all cases with no procedural complications. No patients developed delayed clinical deterioration. One patient was found to have small asymptomatic areas of ischemia in the PICA territory, but it was unclear if these occurred during the initial occlusion or in a delayed fashion. All procedures were performed in less than 4minutes of fluroscopy time using a single device (list price $1750.)
Conclusions: Prophylactic vertebral artery occlusion with the MVP device appears safe and may be a reasonable treatment option to prevent the rare but devastating complication of clot dislodgement during cervical reduction. Compared to alternatives such as coil embolization, the device is a cost effective solution. Further data is needed to better understand the incidence of delayed stroke with fracture dislocation and comparative effectiveness of various treatment options.
Patient Care: We think that this initial series may alert clinicians to this potential problem in order to consider potential strategies to mitigate severe secondary injury.
Learning Objectives: 1- Understand the potential for severe posterior circulation stroke after reduction of cervical fracture dislocation.
2- Describe several potential options to avoid this complication.