Management issues in a case of congenital CV junction anomaly with aberrant retropharyngeal midline course of bilateral cervical ICAs at C1-C2.

Management issues in a case of congenital CV junction anomaly with aberrant retropharyngeal midline course of bilateral cervical ICAs at C1-C2.

World Neurosurg. 2018 Mar 12;:

Authors: Sai Kiran NA, Kiran Kumar VA, Sivaraju L, Kumar VA, Reddy CR, Agrawal A

Abstract
BACKGROUND: Aberrant medial retropharyngeal prevertebral course of internal carotid arteries (ICAs) is extremely uncommon. In oropharyngeal surgeries like trans oral odontoidectomy (TOO) this unrecognized aberrant retropharyngeal course of ICAs can result in devastating complications secondary to inadvertent injury of ICAs. Authors describe this aberrant course of ICAs in a patient with craniovertebral junction (CVJ) anomaly with dysmorphic C1 lateral mass on one side and discuss in detail various management issues in this complex case.
CASE DESCRIPTION: A 44 year old patient presented with neck pain, paresthesias in all 4 limbs and quadriparesis. CT CVJ revealed os odontoideum, basilar invagination (BI), atlantoaxial dislocation (AAD), severe malalignment of C1-C2 facets and unusually thin (dysmorphic) left C1 lateral mass. CT angiogram revealed aberrant medial retropharyngeal course of bilateral cervical ICAs with near midline location at the level of C1 and C2. Transoral odontoidectomy (TOO) was not considered safe in view of potential injury to medially located ICAs. Normal spinal alignment with reduction of BI and AAD was achieved by C1-C2 joint distraction with placement of spacer in only right C1-C2 joint space followed by occipitocervical fusion. Patient showed complete recovery after surgery with improvement of power in all the 4 limbs to 5/5.
CONCLUSION: Identification of this rare aberrant prevertebral course of ICAs in a patient with CVJ anomaly is critical as it precludes TOO as a treatment option. Correction of BI and AAD is possible even with unilateral C1-C2 joint spacer when placement of joint spacer on other side is not feasible technically.

PMID: 29545218 [PubMed - as supplied by publisher]

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