Anterior surgical approaches to the cervical spinal pathology have become a frequently used technique. Anterior cervical spine surgeries are generally considered to be safe with low incidence of neurological complications. Vertebral artery (VA) injuries are infrequent during an anterior cervical spine approach but can be devastating. A retrospective review of these injuries documents an incidence of 0.3%-0.5%. However, there is no established strategy or guidelines for managing iatrogenic VA injuries. We describe a case of iatrogenic VA injury at C5 vertebral level during an anterior cervical approach for C5 cervical osteoblastoma; successful managed by endovascular coiling using detachable coils achieving complete occlusion. The patient had a good clinical outcome, with no symptoms of vertebrobasilar insufficiency at 2-year follow-up. There is a paradigm shift in the management of the VA injury after introduction of the interventional angiography. Endovascular embolization is a safe and effective treatment option, which offers certain advantages over open surgery such as minimal invasion, lower risk of neurological injury, lower morbidity, and recurrence rates.

Dural arteriovenous fistulas (DAVFs) are acquired pathological arteriovenous connections involving vessels that usually supply the meninges. A DAVF in the region of the hypoglossal canal is a rare form of fistula that involves the anterior condylar confluence or anterior condylar vein. We report a case of hypoglossal canal DAVF that was successfully embolized transvenously through a superior ophthalmic vein (SOV) approach. After failed attempts through jugular access, our patient was treated by a unique percutaneous direct puncture approach through the SOV, achieving complete obliteration of the fistula. A step-by-step description of the endovascular technique was described. The clinical course was uneventful without any new neurologic deficit. The eye symptoms and third nerve palsy had completely resolved at the 3-month follow-up visit. Hypoglossal canal DAVFs are rare and may exhibit complex venous drainage patterns. Knowledge of the complex venous anatomy is essential for planning an alternative transvenous route if the standard approach is not feasible. Xper CT (Philips Healthcare, Best, The Netherlands) is an excellent tool for identifying the exact site of the fistula as well as for confirming a safe position of the catheter tip for successful occlusion of this complex dural AV fistula.

Blister aneurysms are intracranial arterial lesions originating at nonbranching sites of the dorsal supraclinoid internal carotid artery and basilar artery.1 Among different treatment options, the use of flow-diverting devices is gaining popularity and has the potential for becoming the standard of care.2 Radiological evaluation of flow diverter braid expansion and vessel wall apposition during procedure has become useful in preventing life-threatening complications. Incomplete coverage of an aneurysm neck, kinking, or incomplete expansion and malapposition of a stent carries a significant risk for thromboembolic events.3 4