PMC9168301_01
Preoperative sagittal CT scan showing the C2 vertebral body fracture II C.
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F1
The CT studies showed an anteriorly displaced odontoid fracture through the base of dens (Anderson D'Alonzo type IIC) on CT scan [Figure 1].
(a) Postoperative CT scan axial cut at the level of C1 showing bilateral lateral mass screws and (b) axial CT cuts at the level of C2 showing right laminar screw. Tract made for pedicle screw insertion on the left side is also appreciated (responsible for fistula formation). (c) Right pedicle screw at C2.
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F2
Immediate postoperatively, the CT CV junction [Figures 2 and 3] showed satisfactorily placed both C1 lateral mass screws and the right-sided C2-pedicle screw with right-sided C2 laminar screw.
Sagittal CT scan showing the position of the screws within C1 vertebral body on the right (a) and left side (b), respectively.
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F3
Immediate postoperatively, the CT CV junction [Figures 2 and 3] showed satisfactorily placed both C1 lateral mass screws and the right-sided C2-pedicle screw with right-sided C2 laminar screw.
(a and b) Postoperative MRI scans with axial sections at the level of cerebellum showing no evidence of infarction following the injury to the left-sided vertebral artery.
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F4
The MRI brain [Figure 4] ruled out any Infarct or hematoma.
Left vertebral artery injection (a) and coronal reformatted image (b) showed vertebra-vertebral fistula at V2 segment with a filling of vertebral venous plexus (arrow) and intervertebral venous plexus (arrowhead). Endovascular treatment was performed using standard tri-coaxial technique, 6 F guide catheter (Envoy, Codman, US) was placed at proximal left vertebral artery. Then, microcatheter (Headway 17, Microvention, US) over microwire (Traxcess 14, Microvention, US) was selectively placed at fistulous junction. Three electro-detachable coils (Cosmos 4 mm x 12 cm, helical 3 mm x6 cm, helical 2.5 mm x 6 cm, Microvention, US) were deployed at fistulous junction under balloon (Scepter C 4 mm x 15 mm, Microvention, US) protection of the left vertebral artery. Final angiogram showed complete occlusion of vertebravertebral fistula. Post coiling left vertebral artery injection (c) and reformatted image (d) showed complete closure of the fistula.
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F5
Specifically, the DSA showed small pseudoaneurysm sac at the superomedial aspect of the V2 segment of the left vertebral artery, with a high flow arteriovenous shunt with early filling and drainage through the cervical epidural venous plexus [Figures 5a and b]. The post procedure angiogram confirmed complete occlusion of vertebra-vertebral fistula, as seen in [Figures 5c and d].