Neurochirurgie 67 (2021) 310–314

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Original article

PICA injury secondary to anterior odontoid screw fixation: Case report

of an exceptional complication夽
K. Farah a,∗ , M. Meyer a , A. Reyre b , K. Cot c , S. Fuentes a
a
Neurosurgery department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
b
Endovascular neuroradiology department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
c
Anesthesiology–intensive care department, Aix-Marseille University, APHM, CHU Timone, Marseille, France

a r t i c l e i n f o a b s t r a c t

Article history: Background. – Odontoid fracture is a common injury in the upper cervical spine that can sometimes be
Received 8 October 2020 managed by anterior odontoid screw fixation.
Received in revised form 15 February 2021 Case description. – We report the first case of iatrogenic postero-inferior cerebellar artery (PICA) injury
Accepted 28 February 2021
while performing anterior odontoid screw fixation for a type II odontoid fracture in a 22-year-old man.
Available online 19 March 2021
Fisher grade 4 subarachnoid hemorrhage secondary to iatrogenic pseudoaneurysm formation was man-
aged by the endovascular neuroradiologist. Odontoid fracture was then managed posteriorly using Harm’s
Keywords:
technique. Postoperative 12-month follow-up revealed good clinical and radiological results. CT scan
Odontoid fracture
Complication
showed fusion. Complete exclusion of the pseudo aneurysm with a mild stroke in the inferior left
Anterior fixation cerebellar hemisphere were noted on the MRI. There were no cerebellar ataxia or swallowing disorders.
Iatrogenic Conclusion. – To the best of our knowledge, this is the first case report of iatrogenic PICA injury in anterior
PICA injury odontoid screw fixation. The patient was well managed in our institution within a multidisciplinary team.
Pseudoaneurysm We recommend that surgical management of odontoid fractures should be performed in expert centres.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction 2. Case report

Odontoid fracture is a common injury in the upper cervical
spine. It accounts for 10% to 16% of all cervical spine fractures
[1,2]. According to the classification of Anderson and D’Alonzo [3],
almost 60% of these fractures are type II cases. Type II fractures and
shallow type III odontoid fractures are recognised as mechanically
unstable and associated with a high incidence of non-union or mor-
tality [3–8] and therefore surgical stabilization is recommended
[9,10].
Some complications may occur during anterior cervical spine
surgery and among these, vascular injury has potentially dev-
astating neurovascular consequences. We report the first case
of iatrogenic PICA injury while performing anterior odontoid
screw fixation for a type II odontoid fracture in a 22-year-old
man.
夽 This paper has not been presented (nor published) previously.
∗ Corresponding author.
E-mail addresses: kaissar.farah@gmail.com, bazramit@hotmail.com (K. Farah).
2.1. Clinical history
A 22-year-old man was assessed to our institution from another
neurosurgical department for the management of iatrogenic left
PICA injury during anterior odontoid screw fixation for post-
traumatic type II odontoid fracture under fluoroscopic control. The
initial surgeon reported CSF leakage with bleeding when retrieving
the K-wire during anterior odontoid screw insertion.
At admission to our institution, patient was under sedation with
endotracheal intubation.
Initial cerebral and cervical spine CT-scan revealed pneumo-
cephalus and perimesencephalic subarachnoid hemorrhage (SAH)
with mild contamination of the ventricles without hydrocephalus
(Fisher grade 4) (Fig. 1) and inappropriate odontoid anterior screw
positioning.
Due to SAH, a first cerebral angiography was performed revea-
ling a 1.5*2 mm pseudoaneurysm of the second segment of the left
PICA with downstream stenosis and delayed filling on parenchy-
mography of the left PICA territory.

https://doi.org/10.1016/j.neuchi.2021.02.015
0028-3770/© 2021 Elsevier Masson SAS. All rights reserved.
K. Farah et al. Neurochirurgie 67 (2021) 310–314

Fig. 1. Head CT scan at admission showing (A) pneumocephalus (black arrow) and Fisher grade 4 perimesencephalic subarachnoid hemorrhage (black arrow) with mild
contamination of the 4th ventricle.

2.2. Surgical management
After a multidisciplinary discussion (neurosurgeons, endovas-
cular neuroradiologists and anesthesiologists), initial management
consisted in close clinical and radiological follow-up. Therefore, a
second cerebral angiography was performed 2 days later showing
a 1.5 mm growth of the pseudoaneurysm. Coiling of the pseudoa-
neurysm was decided and performed with complete occlusion of
the aneurysm’s sac. Left PICA was still permeable on the final con-
trol (Fig. 2).
A week later, the cerebral angiography control revealed recana-
lisation of the pseudoaneurysm within its neck, and the appearance
of a second pseudoaneurysm on the other side of the left PICA
(mirror pseudoaneurysm).
After a new multidisciplinary discussion, we decided a segment
occlusion of the left PICA with coiling and onyx due to the high
bleeding risk. The final control shows an occlusion of the left PICA
at the dissecting aneurysm level (Fig. 3). More distally, the artery is
partially recovered by neighbouring anastomosis. When the patient
was out of risk for rebleeding and pseudoaneurysms were con-
trolled, he underwent posterior C1–C2 fixation according to Harms’
technique [11]. The anterior odontoid screw was not removed as it
did not present any harmful position and in order to avoid compli-
cations secondary to a revision surgery.
2.3. Postoperative course
After 2 weeks in the intensive care unit, the patient was
transferred to our neurosurgical department. Clinical examination
revealed a GCS of 15 out of 15, a mild left cerebellar syndrome
with left dysmetria and disdiadochokinesia with mild swallowing
disorders.
A cerebral MRI was performed and revealed mild infarction
within left PICA territory with disappearance of the SAH. No hydro-
cephalus was noted.
A spine CT-scan obtained 2 days postoperatively demonstrated
adequate screw positioning with no medial breach nor with trans-
verse foramen obstruction and no further displacement of the
fracture (Fig. 4). He was released to a rehabilitation centre 3 weeks
after initial admission.
A 12-month postoperative CT-scan showed fusion of the frac-
ture. The anterior odontoid screw was still in place. Cerebral MRI

Fig. 2. Cerebral angiography (left vertebral artery, lateral view) performed. A. On admission revealing a 1.5*2 mm pseudoaneurysm (grey arrow) of the second segment
of the left PICA with downstream stenosis and delayed filling on parenchymography of the index territory. B. Four days after admission showing a 1.5 mm growth of the
pseudoaneurysm. Coiling was performed. Left PICA was still permeable on the final control.

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K. Farah et al. Neurochirurgie 67 (2021) 310–314

Fig. 3. Cerebral angiography (left vertebral artery, lateral view) performed on day 11 after admission showing (A) recanalisation within the neck (grey arrow). (B) Segment
occlusion of the left PICA with coiling and onyx due to the high bleeding risk was decided (grey arrow), and therefore (C) the left PICA is no more enhanced (grey arrow).

Fig. 4. Postoperative day 2 spine CT-scan showing adequate screw positioning on (A) parasagittal and (B) sagittal (C) and axial slides with neither medial breach nor with
transverse foramen obstruction and no further displacement of the fracture. Note the previous trajectory of the anterior odontoid screw.

Fig. 5. Cerebral MRI. A. Two weeks post-admission, axial hyperFLAIR intensity revealing mild infarction within left PICA territory (white arrow) with disappearance of the
SAH. B. At 6 months follow-up showing a mild stroke in the inferior left cerebellar hemisphere (white arrow) on axial FLAIR sequence and (C) complete exclusion of the
pseudo aneurysm and left PICA (white arrow) on TOF sequence.

revealed complete exclusion of the pseudo aneurysm with a mild
stroke in the inferior left cerebellar hemisphere (Fig. 5). The patient
reported no neck pain. There was no cerebellar ataxia or swallowing
disorders.
No wound problems were to be reported.
3. Discussion
Management of type II odontoid fracture is still controversial.
Several factors can determine treatment’s strategy: Age, fracture’s
orientation, osteoporosis, comorbidities, vertebral artery anatomy,
osseous anomalies [12] and surgical team experience.
Management can be conservative or surgical. When surgery is
selected, surgeons dispose of 3 alternatives: Anterior screw fixa-
tion, C1 lateral mass and C2 pedicle fixation also known as Harm’s
technique or C1–C2 transarticular fixation also known as Magerl’s
technique [13].
Although there are circumstances that require posterior fixa-
tion, anterior odontoid screw fixation confers several advantages,
such as maintenance of atlantoaxial rotation, shorter operative

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K. Farah et al.
times and reduced vertebral artery injury and bleeding risk
[14,15].
3.1. Complication
In a retrospective study reporting short-term complications
of anterior fixation of odontoid fractures in 103 patients with a
mean age of 73.9 years (19–90), complications occurred in 37.9%
of patients. Major complications consisted in death in 7 patients,
unplanned reoperation in 6 patients, failure to wean/re-intubation
in 5 patients, myocardial infarction in 2 patients, sepsis in 2 patients
and stroke in 2 patients. Minor complications were blood trans-
fusion in 23 patients, pneumonia in 4 patients and urinary tract
infection in 3 patients [16].
In another retrospective multicentre study including 14,722
patients, Lee et al. reported that surgery-specific incidence of iatro-
genic vertebral artery injury was 1.35% in cases involving C1–2
posterior fixation and 0.20% in cases involving C3–6 posterior
fixation. Common injury mechanisms were screw-in (31%) and
high-speed drilling (23%). Of 13 cases of iatrogenic vertebral artery
injury, 3 (23%) involved cerebellar or stem infarction; the infarction
had no substantial correlation with injury grade or dominancy [17].
Incidence vary in the literature as vertebral artery injury (and/or
PICA injury) with cerebellar infarction or brain stem infarction
can occur in 1.7 to 5% of patients who underwent surgery using
C1–C2 transarticular fixation [18–20]. Due to the technically more
demanding method of Magerl’s technique, the use of Harms’ tech-
nique is contemporary more popular [12]. However, Yoshida et al.
reported that C2 pedicle screw placement has the same anatomic
risk of the VA injury as transarticular screw placement [21]. Injury
of the PICA is mostly reported in posterior fixation with aberrant
artery anatomy [22].
Several other studies examined complications and mortality in
patients treated with anterior odontoid screw fixation [16,23–25].
Among these studies, none had reported PICA injury during anterior
odontoid screw fixation. We hereby report the first case concerning
this exceptional iatrogenic complication.
3.2. Management
In our case, complication was managed in our expert centre
where intensive care unit, endovascular neuroradiologist and neu-
rosurgeon are present. The posterior fixation using the Harm’s
technique is considered in our case as a viable salvage in the failed
anterior odontoid fixation. At last follow-up, clinical and radiologi-
cal (both healing of the fracture and angio-cerebral MR) results are
very satisfying comparing to the initial condition at admission. We
therefore stress on the necessity to perform this kind of surgery
in centres where all previously cited actors are present and work
closely together in order to rapidly manage complications that can
sometimes be deadly. Surgery for odontoid fracture should also be
managed by an expert surgeon, as there surely is a learning curve
that cannot be neglected. Nowadays, there are many tools that can
technically help surgeon in daily routine for the management of
these fractures such as intraoperative 3D-navigation [26].
4. Conclusion
To the best of our knowledge, this is the first case report of iatro-
genic PICA injury in anterior odontoid screw fixation. The patient
was well managed in our institution within a multidisciplinary
team. We recommend that surgical management of odontoid frac-
tures should be performed in expert centres.
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Neurochirurgie 67 (2021) 310–314
Human and animal rights
The authors declare that the work described has not involved
experimentation on humans or animals.
Informed consent and patient details
The authors declare that this report does not contain any per-
sonal information that could lead to the identification of the
patient(s) and/or volunteers.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
This work did not receive any grant from funding agencies in
the public, commercial, or not-for-profit sectors.
Author contributions
All authors attest that they meet the current International Com-
mittee of Medical Journal Editors (ICMJE) criteria for Authorship.
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