2025 American Academy of Neurology Abstract Website

Objective:

We report a patient with syndromic musculoskeletal abnormalities and intracranial vertebral artery dissection with thrombus near the distal tip of an indwelling piece of hardware from prior C2-T2 spine fusion.

Background:

A 76-year-old male with Job syndrome status post lumbar laminectomy, cervical corpectomy and cage placement with anterior plate/screw fixation due to spinal canal stenosis, subsequent C2-C7 laminectomy with bilateral screw fixation, followed by C2-C3 anterior cervical discectomy/fusion due to left C2 screw malpositioning and right C2 screw head loosening, presented with syncope and 2-week history of brief episodes of headache, dizziness and nausea.

Exam showed short stature, limited neck range of motion, scoliosis, without focal neurological deficits. CT angiogram head and neck showed intraluminal thrombus in the proximal V4 segment of the left vertebral artery with 70% stenosis, at the distal tip of the indwelling cervical hardware. MRI brain showed acute and subacute left cerebellum infarcts. Patient was started on heparin drip and while determining the appropriate neurosurgical intervention, developed new cerebellar infarcts. He underwent occiput to T2 revision, posterior cervical fusion, followed by enoxaparin subcutaneously transitioned to oral apixaban. No bleeding complications and no recurrent ischemic cerebrovascular events were noted to date.

Design/Methods:

Results:

Conclusions:

This case highlights traumatic intracranial vertebral dissection by migrated intraspinal hardware. Posterior C1 arch bone loss caused dorsal to anterior shortening of the distance between the left cervical screw and vertebral artery. Though intraoperative vertebral dissection is a known risk in cervical spine procedures, we report the first case of delayed dissection due to hardware migration through degenerated bone. Secondarily, this case presented unique challenges due to high-risk dissection features, intraluminal thrombus (requiring parenteral anticoagulation) and intracranial vessel dissection (posing additional risk of subarachnoid hemorrhage). Ultimately, given recurrent cerebellar infarcts despite parenteral anticoagulation, urgent neurosurgical intervention to remove the ongoing dissection trigger ensued.