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Potential causes of iatrogenic intraoperative bleeding during C1 surgeries: a CT 3D rendering study
Ping Wang1, Yuezhan Shan2, Lifeng Yu3
1Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, China; Department of Anatomy, Tarim University School of Medicine, Alar, China.
Insights
Iatrogenic bleeding during C1 surgeries can be caused by ponticulus posticus variations and vertebral artery anatomy. Preoperative imaging and careful dissection are crucial to prevent arterial and venous hemorrhage in atlas surgery.
Area of Science:
- Neurosurgery
- Anatomy
- Radiology
Background:
- Iatrogenic intraoperative bleeding during C1 surgeries presents significant management challenges.
- Understanding the anatomical variations contributing to bleeding is critical for surgical safety.
Purpose of the Study:
- To investigate the potential causes of iatrogenic intraoperative bleeding specifically in atlas (C1) surgeries.
- To identify anatomical factors that may lead to arterial and venous hemorrhage during C1 procedures.
Main Methods:
- Retrospective observational cohort study utilizing high-resolution head and neck computed tomography angiography (CTA) images from 551 subjects.
- Analysis of ponticulus posticus (POPO) variations, vertebral artery (VA) course relative to the groove for VA (GVA), and venous plexus communications.
- Three-dimensional rendering was employed to evaluate anatomical relationships and potential bleeding sources.
Main Results:
- Ponticulus posticus (POPO) was identified in 14.07% of atlases, with four distinct types observed.
- The vertebral artery (VA) did not directly contact the GVA sulcus in 42.92% of cases, allowing space for a venous plexus.
- Additional foramina in the posterior C1 lamina, serving as conduits for communicating veins, were present in 12.7% of subjects.
Conclusions:
- Underestimation of POPO and VA variations can lead to arterial bleeding; inadequate understanding of the venous plexus can cause venous hemorrhage.
- Preoperative head and neck CTA is recommended to identify potential bleeding risks.
- Increased caution during dissection in the lateral C1 lamina and consideration of surgical modifications are advised to mitigate iatrogenic hemorrhage.
Background:
Iatrogenic intraoperative bleeding during C1 surgeries is difficult to manage.
Purpose:
To investigate the potential causes of iatrogenic intraoperative bleeding in atlas surgeries.
Study Design:
This was a retrospective study, observational cohort of patients with DICOM.
Patient Sample:
High-resolution head and neck computed tomography angiography (CTA) images from 551 subjects were included.
Outcome Measures:
Ponticulus posticus (POPO), vertebral artery (VA), venous plexus communication.
Methods:
Three dimension rendering was utilized in the present study. Potential arterial bleeding was evaluated based on the variation in the VA and the polymorphism of the POPO over the groove for VA (GVA). The communication of the venous plexus in the occipitoatlantal region was investigated to assess the venous hemorrhage.
Results:
Among the 551 atlases examined, POPOs were identified on 155 sides, resulting in a prevalence of 14.07% (155/1102). These POPOs (n=155) were reclassified into four types: tiny spur (54.84%), long spur (7.10%), ossified bridge (30.32%), and ossified canal (7.74%). In 42.92% (473/1102) of cases, the VA did not directly contact the sulci of the GVA, creating space for the passage of the rich venous plexus that drained intracranial venous blood outflow to various extracranial layers. Moreover, in 12.7% of the subjects, the study revealed the presence of additional foramens in the posterior lamina of C1, which served as a conduit for the communicating vein CONCLUSION: The potential underestimation of polymorphism in POPOs and VAs can lead to arterial bleeding, whereas a lack of understanding of the intricate condylar emissary venous plexus can result in venous hemorrhage. To mitigate iatrogenic hemorrhage during C1 surgeries, a preoperative HEAD AND NECK CTA is recommended, and heightened caution should be exercised during dissection in the lateral half of the C1 lamina. Furthermore, unknown causes of intraoperative bleeding may arise during the posterior C1 approach; modifications should be considered based on the specific circumstances encountered.
