Primary vertebral artery reanastomosis during retrosigmoid skull base approach following iatrogenic near-transection with monopolar electrocautery.

BACKGROUND: Iatrogenic vertebral artery injury is a rare neurosurgical complication, but it is potentially fatal. The majority of vertebral artery injuries are encountered during cervical spine instrumentation, and craniotomy-related injuries have been encountered during the far-lateral approach.

OBJECTIVE: To present the first reported case of iatrogenic vertebral artery injury occurring during retrosigmoid craniotomy, in the setting of an anomalous vertebral artery course within the suboccipital musculature.

METHODS: A 70-year-old man underwent elective retrosigmoid craniotomy for meningioma resection. During exposure, iatrogenic injury to the third segment of the vertebral artery occurred above the craniocervical junction. His vertebral arteries were codominant. The artery was primarily repaired and the operation was aborted. He was treated with aspirin, remained neurologically intact, and was discharged the next day.

RESULTS: Immediate and 5-week vascular imaging studies demonstrated vessel patency. After 5 weeks, the patient returned for elective tumor resection, which was uncomplicated, and he remained neurologically intact at 10-week follow-up.

CONCLUSION: The rarity of vertebral artery injuries and lack of previous such complications involving retrosigmoid craniotomy highlight the need for vigilance during any suboccipital exposure. Complication avoidance is possible by using several preoperative and intraoperative checks. When an injury has occurred, rapid assessment and management of the event is necessary, while primary repair may be more difficult following electrocautery-mediated laceration. Successful treatment of iatrogenic vertebral arterial injuries has been described, but the most frequently reported management has been endovascular sacrifice of the injured vessel, which carries inherent risks of vertebrobasilar insufficiency in a dominant vertebral artery.