Distal and proximal embolization for penetrating vertebral artery injury: illustrative case.

backgroundWhen treating a penetrating vertebral artery (VA) injury, blindly removing a foreign object that has pierced the artery can lead to distal embolism due to thrombus formation at the penetration site and uncontrollable hemorrhage during foreign object removal. OBSERVATIONS: A 68-year-old man was impaled in the posterior neck by a 7-cm metal rod during brush cutting. Neither neurological deficits nor active bleeding was observed. CT revealed that the metal rod had penetrated between the left C1 and C2 transverse foramina, and CT angiography showed occlusion at the V2 segment of the left VA. Retrograde distal embolization via a contralateral approach was performed, followed by proximal embolization to achieve complete occlusion before rod removal. No arterial bleeding occurred during rod removal. Postoperative MRI revealed a small infarct in the left cerebellum, but no neurological deficits were present. LESSONS: In cases of penetrating VA injury with a retained foreign object, vascular evaluation and embolization should be considered before foreign object removal. Retrograde distal embolization via a contralateral approach, combined with proximal embolization, may be an effective strategy for preventing distal embolism and controlling hemorrhage. https://thejns.org/doi/10.3171/CASE25435.