Korean J Neurotrauma.  2019 Oct;15(2):192-198. 10.13004/kjnt.2019.15.e27.

Posterior Inferior Cerebellar Artery Infarction Originating at C1-2 after C1-2 Fusion

• Won D
• Lee JM
• Park IS
• Lee CH
• Lee K
• Kim JY
• Lee YS

• KMID: 2461127
• DOI: http://doi.org/10.13004/kjnt.2019.15.e27

Abstract

Vertebral artery injuries associated with C1 lateral mass screw insertion rarely occur during C1-2 fusion. The posterior inferior cerebellar artery (PICA) is uncommonly located at the C1 lateral mass insertion position. A 71-year-old woman with atlanto-axial subluxation and cord compression underwent C1-2 fusion. Sixth nerve palsy and diplopia were detected postoperatively, and decreased consciousness occurred on postoperative day 4. Brain magnetic resonance image (MRI) and computed tomography (CT) revealed PICA infarction. In the preoperative CT angiography, the PICA originated between the C1 and C2 level. In the postoperative CT scan, the PICA was not visible. The patient was treated conservatively for two weeks and recovered. PICA originating between the C1 and C2 level comprises 1.1-1.3% of cases. Therefore, vertebral artery anomalies should be evaluated prior to C1-2 fusion to prevent vessel injuries.

Keyword

Atlanto-axial fusion; Brain infarction; Vertebral artery; Posterior inferior cerebellar artery

MeSH Terms

Abducens Nerve Diseases
Aged
Angiography
Arteries*
Brain
Brain Infarction
Consciousness
Diplopia
Female
Humans
Infarction*
Pica
Tomography, X-Ray Computed
Vertebral Artery

Figure

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  FIGURE 1 Preoperative images. (A) C-spine plain radiography, lateral view (ADI = 5 mm, PADI = 10.4 mm). (B, C) C-spine magnetic resonance image T2 sagittal and T2 axial view showing cord compression with right foraminal stenosis on C1-2.ADI: atlanto-dens interval, PADI: posterior atlanto-dens-interval.

• 

  FIGURE 2 Postoperative plain radiographics. (A) Anteroposterior view and (B) Lateral view.

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  FIGURE 3 Postoperative brain magnetic resonance images and computed tomography angiography images taken on postoperative day 4. (A) Diffusion-weighted image, (B) Mean transit time image showing acute infarction at the left cerebellum, and (C, D) Comparison with preoperative image (arrow). The left posterior inferior cerebellar artery is not shown (arrowhead).

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  FIGURE 4 Schemas of vertebral artery variation observed at the C1-2 level (left lateral view). (A) Persistent first intersegmental artery, (B) Fenestration of the vertebral artery above and below C1, (C) Posterior inferior cerebellar artery (white arrow) originating from the C1-2 level, and (D) High-riding vertebral artery.

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  FIGURE 5 Comparisons between preoperative and postoperative images (day 4) of computed tomography angiography. (A) The left posterior inferior cerebellar artery begins between the C1-2 and progresses cephalad towards the cerebellum in the preoperative image (white arrow). (B) The left posterior inferior cerebellar artery may be injured or compressed by the left C1 lateral mass screw (white arrow), and the artery is not seen on the postoperative image (white arrowhead).

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