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Background Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumentation. A better understanding of clinical outcome and management options following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumentation. Methods We performed a systematic review of the Medline database following PRISMA guidelines. In our analysis, we included any retrospective cohort studies, prospective cohort studies, case reports, cases series, or systematic reviews with patients who had undergone posterior atlanto-axial fusion via screw rod constructs (SRC) or transarticular screws (TAS) that reported a patient with an injury to an arterial vessel directly attributable to the surgical procedure. Results Sixty cases of vascular injury were reported in 2078 (2.9%) patients over 27 publications. The average age for this patient population was 55.7+/−17.9. Vascular injury following posterior C1/2 instrumentation resulted in ipsilateral stroke in 10.0% (n = 6/60) and non-persistent neurologic deficit in 6.7% (n = 4/60) of cases with the deficit being permanent (not including death) in 1.7% (n = 1/60) of cases. Four patients (6.7%) died. Arteriovenous fistula or pseudoaneurysm occurred in 8.3% (n = 5/60) and 3.3% (n = 2/60) of cases, respectively. Eight patients (13.3%) underwent endovascular repair of the injury with no permanent deficit. Conclusion Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. Some patients may benefit from endovascular treatment. Surgeons should be aware of normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic complication.

Background Carotid endarterectomy (CEA) is one of the most commonly performed and studied surgical procedures for extracranial ischemic disease. Objective The authors reviewed the outcome of 39 consecutive carotid endarterectomy procedures performed by a single surgeon with emphasis on the safety of discharging patients the same day of the procedure. Methods Retrospective analysis was performed over a two-year period on patients who were admitted as outpatients and underwent CEA. Following CEA, patients were observed for 4–6 h in the recovery room and Duplex ultrasonography was completed to assess the endarterectomy repair. Determination was then made whether patients could be safely discharged home. Results Over a two year period, CEA was performed 39 times in 37 outpatients. Twenty-five patients (64%) were discharged within 6 h of surgery completion. The remaining 14 patients (36%) were admitted to the hospital for varying reasons. Six patients (43%) stayed either due to personal preference or the lack of supervision at home and six other patients (43%) stayed because of mild hemodynamic instability. Of the two remaining patients, one was admitted for chest pain and the other for a small wound hematoma. No patients developed postoperative neurologic deficits. Two-tailed Fisher test analysis of collected variables revealed that patients who had general anesthesia were more likely to be admitted (p Conclusion Patients undergoing CEA can be safely discharged the same day after a brief period of postoperative observation. One factor that may predict the need for postoperative admission is the use of general anesthesia.

Introduction Type II odontoid fractures are the most common spinal fracture in the elderly population and may be managed with halo immobilization, posterior fusion, and anterior odontoid screw fixation. Anterior odontoid screw fixation has several advantages over posterior fusion, including: reduced surgical time, decreased post-operative pain, preserved range of motion, earlier mobilization, and decreased postoperative narcotic requirement. We review our experience using anterior odontoid screw fixation in type II odontoid fractures in the elderly and non-elderly populations. Methods Demographic and outcome data were retrospectively collected in 30 consecutive patients with type II odontoid fractures treated with anterior odontoid screw fixation. Results Mean patient age was 70.7 (range 20–92); 18 of the patients were male and 12 were female. All patients had successful placement of a single anterior odontoid screw without intra-operative complication. Complications included pneumonia in nine patients (30%), gastrostomy tube placement due to patient failing swallow evaluation in 13 patients (43%), and vocal cord paralysis in one patient (3.3%). Patients over the age of 75 accounted for 12 of the 13 (92%) gastrostomy tube placements and eight of the nine (88.9%) pneumonias, respectively. The difference in rates of gastrostomy tube placement and pneumonia for the older patients were both found to be statistically significant with P P Conclusions Anterior odontoid screw fixation is an effective treatment option for patients with Type II odontoid fractures. In the elderly population, however, the benefits of the procedure must be weighed against the risks of postoperative dysphagia requiring gastrostomy and pneumonia.

Objectives Acute cervical carotid occlusion is one of the most challenging scenarios encountered in endovascular stroke treatment. Patients and methods A retrospective analysis of 11 consecutive non-dissection stroke patients with concomitant cervical carotid and intracranial occlusion treated with intraarterial (IA) mechanical thrombectomy and/or pharmacologic thrombolysis over five years at two academic hospitals was performed. Data was analyzed using Fisher's exact test. Results Patients included 3 females and 8 males. Average age was 64.7 years (range 30–94 years). All patients had both cervical carotid and intracranial occlusions. Intracranial occlusion involved the internal carotid artery in 7 patients and the middle cerebral artery in 4 patients. All of the patients received intracranial IA Tissue Plasminogen Activator (tPA). Six patients received carotid stents for cervical occlusion as part of their treatment. Five patients received only IA tPA via collateral circulation. Of the patients receiving stents, 5 of 6 (83.3%) had successful recanalization (Thrombolysis in Cerebral Ischemia 2b or 3 flow). Only 1 of 5 (20%) patients who did not receive stents prior to intracranial treatment had successful recanalization. The difference in recanalization rates approached statistical significance ( p =.08). There were 4 total in-hospital mortalities: 2 in the group that received stents prior to thrombolysis and 2 in the non-stent group. There were 2 clinically significant hemorrhages in the study, both in the stent group. Conclusions Revascularization of the cervical carotid occlusion prior to treatment of the intracranial occlusion led to increased rates of recanalization in patients with tandem extracranial and intracranial occlusions. Whether a clinical benefit can be consistently derived likely relies on other factors, including the evaluation of cerebral perfusion.