Vertebral artery injury after blunt cervical trauma: an update

Treatment Strategy for Subaxial Minimal Facet/Lateral Mass Fractures: A Comprehensive Clinical Review

Minimal facet and lateral mass fractures of the subaxial cervical spine (C3-C7) are a distinct subset of spinal injuries that present diagnostic and therapeutic challenges. These fractures often result from low-energy trauma or hyperextension mechanisms. They are frequently stable. However, subtle fracture instability and associated soft tissue injuries may lead to delayed instability, neurological compromise, and/or chronic severe pain if not properly identified. Accurate diagnosis relies on a combination of plain radiography, high-resolution computed tomography (CT), and magnetic resonance imaging (MRI) to assess bony and ligamentous integrity. Treatment strategy is determined based on fracture stability, neurological status, and radiographic findings. Most stable fractures can be effectively treated with conservative treatment, allowing for natural healing while minimizing complications. However, when instability is suspected-such as those with significant disc and ligamentous injuries, progressive deformity, or neurological deficits-surgical stabilization may be considered. The presence of vertebral artery injury (VAI) can further complicate management. To mitigate the risk of stroke, a multidisciplinary approach that includes neurosurgery, vascular surgery, and interventional radiology is needed. Surgical treatment aims to restore spinal alignment, maintain stability, and prevent further neurological deterioration with approaches tailored to individual fracture patterns and patient-specific factors. Advances in surgical techniques, perioperative management, and endovascular interventions for VAI continue refining treatment options to improve clinical outcomes while minimizing complications. Despite increasing knowledge of these fractures and associated vascular injuries, optimal treatment strategies remain unclear due to limited high-quality evidence. This review provides a comprehensive analysis of the anatomy, biomechanics, classification, imaging modalities, and treatment strategies for minimal facet and lateral mass fractures in the subaxial cervical spine, highlighting recent advancements in diagnostic tools, therapeutic approaches, and managing vertebral artery injuries. A more precise understanding of the natural history and optimal management of these injuries will help spine specialists refine clinical decision-making and improve patient outcomes.

Traumatic Vertebral Artery Injury After Subaxial Cervical Spine Injuries: Incidence, Risk Factors, and Long-Term Outcomes: A Population-Based Cohort Study

BACKGROUND AND OBJECTIVES

Vertebral artery injury (VAI) because of traumatic subaxial cervical spine injury is a rare but potentially devastating condition as it could lead to stroke. The aim of this study was to examine the incidence, risk factors, outcomes, and radiographic predictors of VAI in patients surgically treated for subaxial cervical spine injuries at a tertiary care trauma center.

METHODS

This is a retrospective population-based cohort study, including all patients surgically treated for traumatic subaxial cervical spine injuries at the study center between 2006 and 2018. Primary outcomes included mortality and morbidity after the injury. Propensity score matching, survival, univariable, and multivariable analyses were used to study the outcomes of interest.

RESULTS

Traumatic VAI primarily occurred after high-energy traumas such as motor vehicle accidents and falls from heights. The median age was 64.4 years (47.4-69.1), and 69% were male. In the cohort of patients with subaxial cervical injury, 54% had a spinal cord injury (SCI). In the subgroup with VAI, the frequency of SCI was 66% and a concomitant SCI and VAI were associated with a more severe American Spinal Cord Injury Association Impairment Scale grade ( P = .015). However, after accounting for age, sex, and associated injuries, VAI did not affect postoperative complications, short- or long-term outcomes, or mortality rates. Facet joint dislocation was a unique radiographic predictor of VAI (odds ratio 3.8 [CI 1.42-10.7], P = .009).

CONCLUSION

The findings suggest that clinical outcomes of patients with traumatic cervical spine injuries were not negatively affected by the presence of a VAI. Several radiographic factors were associated with VAI; however, only facet joint dislocation remained as an independent predictor of this injury.

Is Vertebral Artery Injury After Blunt Cervical Spine Trauma an Incidental Finding?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To understand the associations between vertebral artery injury (VAI) and adverse events in patients sustaining blunt cervical spine trauma.

SUMMARY OF BACKGROUND DATA

To date, the impact of VAI on adverse events, and by extension, clinical outcomes has been extracted from small patient cohorts and have not allowed definitive conclusions.

METHODS

Adult patients with cervical vertebral, ligamentous, or neurological trauma in the National Trauma Data Bank from 2016 to 2017 were included in the study. Demographic information (age, sex, and race), injury-specific information (mechanism, severity), patient health information, and presence of a VAI were collected as explanatory variables. Response variables included development of adverse events [DVT/PE, myocardial infarction (MI), stroke, hemorrhage, or neurological deficit] length of stay (LOS) and unplanned ICU admission or surgical procedure. Multivariable regression was used to calculate the risk-adjusted effect of vertebral artery injury on the presence of adverse and unplanned events as well as its relationship with LOS.

RESULTS

Totally, 128,908 patients with cervical trauma were reviewed, of which 5300 had VAI. Of the patients with VAI, 187 (3.5%) patients had a MI, 156 (2.9%) had a PE/DVT, 196 (3.7%) had a stroke, 1392 (26.3%) had neurological injury, and 443 (8.4%) had an unplanned operative procedure or ICU admission. After risk-adjustment, VAI was associated with a >2-fold increased risk of increased LOS and ICU LOS (P<0.001), as well as greater than a 2-fold increased risk of MI, PE/DVT, stroke, and neurological injury (P<0.001).

CONCLUSIONS

Our study documented a higher rate of concomitant VAI in blunt cervical trauma than previously reported. VAI is a hallmark of a more severe or higher energy mechanism of injury and is associated with increased adverse events and LOS in the hospital/ICU. In addition, these data suggest that, in older patients, concomitant VAI is associated with adverse outcomes independent of mechanism of injury.

LEVEL OF EVIDENCE

Step II-diagnostic study.

Blunt Traumatic Vertebral Artery Injury After Cervical Fracture Dislocation: A Systematic Review of the Literature

Certain high-energy blunt forces may produce unstable cervical fractures with or without dislocation. In rare cases where the superior facets are dislocated, however showing a significant increase within the last decade, these types of injuries may include vertebral artery entrapment at the involvement level leading to artery dissection or occlusion. This phenomenon is usually seen at the C4-C5 and C5-C6 levels of injury. A systematic review of the literature was performed by examining online databases such as PubMed - NCBI, Web of Science, Cochrane Library, Scopus, and Embase to identify relevant scientific articles. Keywords (MeSH terms) used in the search included cervical spine injuries, cervical spine dislocation, cerebrovascular injury, vertebral artery injury, vertebral artery injury management, and incidence of vertebral artery injury. Initially, 1516 studies were identified as a primary search for screening. After excluding papers that did not fulfill the inclusion criteria, 34 studies were included in this review. Vertebral artery injury consists of a severe complication that could compromise a surgical intervention since the patient's clinical image may be unrevealing at first. Early diagnosis and correct timing constitute the golden standard for adequate treatment. This systematic review aims to summarize the current evidence for the diagnosis, management, and treatment of blunt traumatic vertebral artery injuries.

Massive Hemorrhage Associated With Upper Cervical Vertebral Fracture Treated Successfully With Transcatheter Arterial Embolization: A Case Report

Blunt vertebral artery injuries (BVAI) associated with cervical spine fractures are often problematic due to symptoms of occlusion. Denver grade V cases, in which the vertebral artery is transected, are rare but often fatal, and treatment has rarely been reported. We encountered a case of hemorrhagic shock due to an injury to a branch of the vertebral artery associated with an upper cervical spine fracture. Transcatheter arterial embolization was performed successfully to achieve hemostasis, requiring superselective arterial embolization to preserve the main trunk of the vertebral artery. It is important to be aware that vascular injuries to the branch vessels as well as the main trunk can cause complications.

Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery

Background

Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD).

Case presentation

A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries.

Conclusions

Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.

Perioperative stroke in patients undergoing spinal surgery: a retrospective cohort study

BACKGROUND

The incidence of perioperative stroke following spinal surgery, including ischemic and hemorrhagic stroke, has not been fully investigated in the Chinese population. Whether specific spinal or emergency/elective procedures are associated with perioperative stroke remains controversial. This study aimed to investigate the incidence of perioperative stroke, health economic burden, clinical outcomes, and associated risk factors.

METHOD

A retrospective cohort study using an electronic hospital information system database was conducted from Jan 1, 2015, to Jan 1, 2021, in a tertiary hospital in China. Patients aged ≥18 years who had undergone spinal surgery were included in the study. We recorded patient demographics, comorbidities, and health economics data. Clinical outcomes included perioperative stroke during hospitalization and associated risk factors. The patients' operative data, anesthetic data, and clinical manifestations were recorded.

RESULT

A total of 17,408 patients who had undergone spinal surgery were included in this study. Twelve patients had perioperative stroke, including seven ischemic stroke (58.3%) and five hemorrhagic stroke (41.7%). The incidence of perioperative stroke was 0.07% (12/17,408). In total, 12 stroke patients underwent spinal fusion. Patients with perioperative stroke were associated with longer hospital stay (38.33 days vs. 9.78 days, p < 0.001) and higher hospital expenses (RMB 175,642 vs. RMB 81,114, p < 0.001). On discharge, 50% of perioperative patients had severe outcomes. The average onset time of perioperative stroke was 1.3 days after surgery. Stroke history (OR 146.046, 95% CI: 28.102-759.006, p < 0.001) and hyperlipidemia (OR 4.490, 95% CI: 1.182-17.060, p = 0.027) were associated with perioperative stroke.

CONCLUSION

The incidence of perioperative stroke of spinal surgery in a tertiary hospital in China was 0.07%, with a high proportion of hemorrhagic stroke. Perioperative stroke patients experienced a heavy financial burden and severe outcomes. A previous stroke history and hyperlipidemia were associated with perioperative stroke.

Existence of knowledge silos in the adult blunt cerebrovascular injury literature

Background

Blunt cerebrovascular injuries (BCVI) remain a significant source of disability and mortality among trauma patients. The purpose of the present study was to determine whether knowledge silos exist in the overall BCVI literature.

Methods

An object-oriented programmatic script written in Python programming language was used to extract and categorize articles and references on the topic of BCVI. Additionally, each BCVI article was searched for by digital object identifier in the other BCVI references to build a network analysis and visualize topic reference patterns. Analyses were performed using Stata V.14.2 (StataCorp).

Results

A total of 306 articles with 10 282 references were included for analysis. Of these, 24% (74) were published in neurosurgery journals, 45% (137) were published in trauma journals, and 31% (95) were published in a journal of another specialty. Similar proportions were found when categorized by author departmental affiliation. Trauma surgery authors disproportionately referenced articles in the trauma literature, compared with neurosurgeons (73.5% vs. 48.0%, p<0.0001), and other authors. The biggest factor influencing reference proportions was the specialty of the publishing journal. Finally, a network analysis revealed that there are more trauma BCVI articles, and there are more frequently cited trauma BCVI articles by all specialties.

Conclusions

This study revealed the existence of a one-way knowledge silo in the BCVI literature. However, a robust preference by both trauma and neurosurgery to cite trauma references when publishing in trauma journals may indicate a possible conscious curating of citations by authors to increase the likelihood of publication. These observations highlight the need for an active role by journal editors, peer reviewers, and authors to actively foster diversity of citations and cross-specialty collaboration to improve dissemination of information between these specialties.

Level of evidence

Level IV. Observational study.

Vertebral Artery Injury in the Cervical Spine: Anatomy, Diagnosis, and Management

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Although rare, injury to the vertebral artery (VA) can occur after blunt trauma or iatrogenically during surgery. Clinicians should be aware of the anatomic variants of the VA, the presence of which may increase the risk of iatrogenic VA injury (VAI).

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If VAI is suspected following blunt trauma, rapid identification via advanced imaging modalities, such as computed tomography angiography, can help clarify the site of injury and guide management.

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VAI can be classified according to the Denver grading scale for blunt cerebrovascular injury, ranging from grade I to grade V, which includes intimal narrowing, pseudoaneurysm formation, complete occlusion, and arterial transection.

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Treatment modalities remain controversial and include anticoagulation, endovascular interventions, surgical tamponade, ligation, and microvascular repair. The choice of treatment is influenced by the setting of the injury (iatrogenic injury in the operating room versus blunt trauma in the field) and the laterality of the dominant VA with respect to brain perfusion.

Cervical Computed Tomography Angiography Rarely Leads to Intervention in Patients With Cervical Spine Fractures

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate the impact of computed tomography angiography (CTA) in the management of trauma patients with cervical spine fractures by identifying high-risk patients for vertebral artery injury (VAI), and evaluating how frequently patients undergo subsequent surgical/procedural intervention as a result of these findings.

METHODS

All trauma patients with cervical spine fractures who underwent CTA of the head and neck at our institution between January 2013 and October 2017 were identified. Patients were indicated for CTA according to our institutional protocol based on the modified Denver criteria, and included patients with cervical fractures on scout CT. Those with positive VAI were noted, along with their fracture location, and presence or absence of neurological deficit on physical examination. Statistical analysis was performed and odds ratios were calculated comparing the relationship of cervical spine fracture with presence of VAI.

RESULTS

A total of 144 patients were included in our study. Of those, 25 patients (17.4%) were found to have VAI. Two patients (1.4%) with VAI underwent subsequent surgical/procedural intervention. Of the 25 cervical fractures with a VAI, 20 (80%), were found to involve the upper cervical region (4.2 OR, 95% CI 1.5-12.0; P = .007). Of the 25 who had a VAI, 9 were unable to undergo reliable neurologic examination. Of the remaining 16 patients, 5 (31.3%) had motor or sensory deficits localized to the side of the VAI, with no other attributable etiology.

CONCLUSIONS

Cervical spine fractures located in the region of the C1-C3 vertebrae were more likely to have an associated VAI on CTA. VAI should also be considered in cervical trauma patients who present with neurological deficits not clearly explained by other pathology. Despite a finding of VAI, patients rarely underwent subsequent surgical or procedural intervention.

Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury

BACKGROUND

Blunt cerebrovascular injury (BCVI) represents a spectrum of traumatic injuries to the carotid and vertebral arteries that is an often-overlooked source of morbidity and mortality. Its incidence, risk factors, and effect on outcomes in patients with mild or moderate traumatic brain injury (mTBI) have not been studied independently.

METHODS

The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with mTBI who suffered blunt injuries. BCVI was identified using abbreviated injury scores and included blunt carotid artery injury (BCAI) and blunt vertebral artery injury (BVAI). A binary logistic regression was used to identify patient-related and injury-related factors associated with BCVI. Binary logistic regressions were also performed to evaluate the effect of BCVI on stroke, in-hospital mortality, nonroutine discharge disposition, total length of stay (LOS), intensive care unit LOS, and number of days mechanically ventilated.

RESULTS

Of 485,880 patients with mTBI, there were 4,382 (0.9%) with BCVI. Cervical spine fracture was the strongest factor associated with BCAI (odds ratio [OR], 1.97; 95% confidence interval [95% CI], 1.77-2.19), followed by mandible fracture and basilar skull fracture. Cervical spine fracture also had the strongest association with BVAI (OR, 18.28; 95% CI, 16.47-20.28), followed by spinal cord injury and neck contusion. Stroke was more common in patients with BCAI (OR, 5.50; 95% CI, 4.19-7.21) and BVAI (OR, 7.238; 95% CI, 5.929-8.836). BVAI increased the odds of mortality, but BCAI did not. Both were associated with nonroutine discharge and increased LOS, intensive care unit LOS, and number of days mechanically ventilated.

CONCLUSIONS

The incidence of BCVI in patients with mTBI is low, and it usually does not require invasive treatment. However, it is associated with greater odds of stroke and negative outcomes. Knowledge of risk factors for BCVI may tailor further investigation to aid prompt diagnosis.

Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options

Unstable traumatic cervical spine fracture is a commonly encountered neurosurgical issue. Concomitant vertebral artery injuries present a challenge in surgical decision-making regarding the timing and order of surgical intervention with respect to endovascular intervention and internal fixation of the unstable fracture. Currently, there are no studies that have specifically examined stroke rate or outcomes for patients who have vertebral artery injuries and unstable cervical spine fractures with respect to temporal treatment course. The purpose of this paper is to review the current evidence for the standards of diagnosis and management of vertebral artery injuries with coinciding unstable cervical spine injuries and propose an evidence-based algorithm for workup and treatment.

Cervical Spine Fractures: Who Really Needs CT Angiography?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Compare a novel two-step algorithm for indicating a computed tomography angiography (CTA) in the setting of a cervical spine fracture with established gold standard criteria.

SUMMARY OF BACKGROUND DATA

As CTA permits the rapid detection of blunt cerebrovascular injuries (BCVI), screening criteria for its use have broadened. However, more recent work warns of the potential for the overdiagnosis of BCVI, which must be considered with the adoption of broad criteria.

METHODS

A novel two-step metric for indicating CTA screening was compared with the American College of Surgeons guidelines and the expanded Denver Criteria using patients who presented with cervical spine fractures to a tertiary-level 1 trauma center from January 1, 2012 to January 1, 2016. The ability for each metric to identify BCVI and posterior circulation strokes that occurred during this period was assessed.

RESULTS

A total of 721 patients with cervical fractures were included, of whom 417 underwent CTAs (57.8%). Sixty-eight BCVIs and seven strokes were diagnosed in this cohort. All algorithms detected an equivalent number of BCVIs (52 with the novel metric, 54 with the ACS and Denver Criteria, P = 0.84) and strokes (7/7, 100% with the novel metric, 6/7, 85.7% with the ACS and Denver Criteria, P = 1.0). However, 63% fewer scans would have been needed with the proposed screening algorithm compared with the ACS or Denver Criteria (261/721, 36.2% of all patients with our criteria vs. 413/721, 57.3% with the ACS standard and 417/721, 57.8%) with the Denver Criteria, P < 0.0002 for each).

CONCLUSION

A two-step criterion based on mechanism of injury and patient factors is a potentially useful guide for identifying patients at risk of BCVI and stroke after cervical spine fractures. Further prospective analyses are required prior to widespread clinical adoption.

LEVEL OF EVIDENCE

4.

Evaluation of a Traumatic Vertebral Artery Occlusion

BACKGROUND

Penetrating neck injury occurs in 5%-10% of all trauma cases and carries a significant burden of morbidity and mortality (15%). We describe the evaluation and management of a 25-year-old man shot in the neck with occlusion of the left vertebral artery from its origin to C6. This is a case report in which medical data were analyzed retrospectively with institutional review board approval.

CASE DESCRIPTION

Neurologic examination revealed paresthesias and dysesthesias in a left C8 dermatomal distribution. Computed tomography angiography of the neck demonstrated no opacification of the left vertebral artery from its origin to C6. Magnetic resonance imaging of the cervical spine revealed an acute infarct in the left cerebellum. A cerebral angiogram highlighted hemodynamic compromise, and the patient was felt to be at significant risk of further cerebral infarction. Augmenting flow to the posterior circulation would mitigate that risk. The patient was taken to the operating room for a transposition of the vertebral artery to the common carotid artery.

CONCLUSIONS

The patient presented with silent cerebellar infarction due to a vertebral artery injury and impending vertebrobasilar insufficiency. This case demonstrates clinical evaluation of the posterior circulation and treatment with a bypass technique through mobilization of the vertebral artery from the boney vertebral foramen with anastomosis to the common carotid.

Management of Sub-axial Cervical Spine Injuries

Sub-axial cervical spine injuries are commonly seen in patients with blunt trauma. They may be associated with spinal cord injury resulting in tetraplegia and severe permanent disability. Immobilization of the neck, maintenance of blood pressure and oxygenation, rapid clinical and radiological assessment of all injuries, and realignment of the spinal column are the key steps in the emergency management of these injuries. The role of intravenous methylprednisolone administration in acute spinal cord injuries remains controversial. The definitive management of these injuries is based upon recognition of the fracture pattern, assessment of the degree of instability, the presence or absence of neurologic deficit, and other patient related factors that may influence the outcome. Nonoperative treatment comprises of some form of external immobilization for 8 to 12 weeks, followed by imaging to assess fracture healing, and to rule out instability. The goals of surgery are realignment of the vertebral column, decompression of the neural elements and instrumented stabilization.

Perioperative stroke in patients undergoing elective spinal surgery: a retrospective analysis using the Japanese diagnosis procedure combination database

BACKGROUND

Although a few studies on perioperative stroke following spinal surgery have been reported, differences in the incidence of perioperative stroke among various surgical procedures have not been determined. The purpose of this retrospective analysis was to investigate the incidence of perioperative stroke during hospitalization in patients undergoing elective spinal surgery, and to examine whether the incidence varied according to the surgical procedure.

METHODS

A retrospective analysis of data from the Diagnosis Procedure Combination database, a nationwide administrative impatient database in Japan, identified 167,106 patients who underwent elective spinal surgery during 2007-2012. Patient information extracted included age, sex, preoperative comorbidity, administration of blood transfusion, length of hospitalization, and type of hospital. Clinical outcomes included perioperative stroke during hospitalization, and in-hospital death.

RESULTS

The overall incidence of perioperative stroke was 0.22 % (371/167,106) during hospitalization. A logistic regression model fitted with a generalized estimating equation showed perioperative stroke was associated with advanced age, a history of cardiac disease, an academic institution, and resection of a spinal tumor. Patients who underwent resection of a spinal cord tumor (reference) had a higher risk of stroke compared with those undergoing discectomy (odds ratio (OR), 0.29; 95 % confidence interval (CI), 0.14-0.58; p = 0.001), decompression surgery (OR, 0.44; 95 % CI, 0.26-0.73; p = 0.001), or arthrodesis surgery (OR, 0.55; 95 % CI, 0.34-0.90); p = 0.02). Advanced age (≥80 years; OR, 5.66; 95 % CI, 3.10-10.34; p ≤ 0.001), history of cardiac disease (OR, 1.58; 95 % CI, 1.10-2.26; p = 0.01), diabetes (OR, 1.73; 95 % CI, 1.36-2.20; p ≤ 0.001), hypertension (OR, 1.53; 95 % CI, 1.18-1.98; p = 0.001), cervical spine surgery (OR, 1.44; 95 % CI, 1.09-1.90; p = 0.01), a teaching hospital (OR, 1.36; 95 % CI, 1.01-1.82; p = 0.04), and length of stay (OR, 1.008; 95 % CI, 1.005-1.010; p ≤ 0.001) were also risk factors for perioperative stroke.

CONCLUSIONS

Perioperative stroke occurred in 0.22 % of patients undergoing spinal surgery. Resection of a spinal cord tumor was associated with increased risk of perioperative stroke as well as advanced age, comorbidities at admission, cervical spine surgery, surgery in a teaching hospital, and length of stay.

Traumatic bilateral carotid artery dissection following severe blunt trauma: a case report on the difficulties in diagnosis and therapy of an often overlooked life-threatening injury

BACKGROUND

Traumatic carotid artery dissections are very rare, often overlooked and life-threatening injuries. Diagnosis and treatment are difficult especially in multiple injured patients.

CASE PRESENTATION

We report on a 28-year-old female major trauma patient (injury severity score, ISS 50) who was involved in a motor vehicle accident. She was primarily transferred to a level II trauma center. After initial assessment and operative management, an anisocoria was diagnosed on the intensive care unit. Subsequent CT angiography and extracranial duplex sonography revealed a bilateral internal carotid artery dissection. The patient was transferred to our level I trauma center where conservative treatment with high-dose heparin therapy was started at day two after trauma. Outcome after 6 months was very good.

CONCLUSION

Besides presenting the case and outcome of this patient, the article discusses the diagnostic and therapeutic management of this extremely rare and often overlooked dangerous injury. To avoid overlooking carotid artery dissections, CT angiography of the neck region should be generously included into the initial multislice CT whole-body scan, when the injury results from an according trauma. For the best outcome, sites of hemorrhage should be abolished quickly and the anticoagulative therapy should be initiated as soon as possible. Interdisciplinary treatment of trauma surgeons and neurologists is crucial.

Traumatic Subarachnoid Hemorrhage Originating from Mid-Cervical Arterial Injury

BACKGROUND

Subarachnoid hemorrhage (SAH) occasionally originates from extracranial arteries, and SAH caused by cervical trauma is even rarer.

CASE REPORT

A 17-year-old male patient was admitted to our emergency department aftera bike accident; he was drowsy and showed left hemiparesis. Initial computed tomography (CT) of the brain showed SAH into the cervicomedullary cistern. A 4-hour follow-up brain CT revealed heavy bleeding into the basal cistern. Because CT angiography did not show any vascular injury, we performed imaging studies of the cervical spine. Magnetic resonance imaging revealed a blood clot located ventral to the C4-C5 level of the spinal cord without any flow void. The patient's condition deteriorated over time, and he was accordingly referred for surgery. Intraoperatively, a thick subarachnoid hematoma ventral to the spinal cord was observed. The hematoma was removed and hemostasis by bipolar cauterization was performed for bleeding from a small branch of the anterior spinal artery. Postoperatively, the weakness of the lower extremity improved considerably.

CONCLUSION

In young adult patients with SAH of unexplained origin, we suggest that the cervical region be considered as the bleeding focus; in such cases, surgical evacuation of bleeding can save some patients.

Posttraumatic hemicerebral infarction in a four-year-old girl

INTRODUCTION

Brain infarction after trauma is uncommon. Injury of the carotid and vertebrobasilar arteries can cause brain infarction due to occlusion of brain blood flow.

CASE PRESENTATION

Emergency medical service (EMS) brought a 4-year-old girl involved in a car accident to the emergency room. She had had seizure controlled by diazepam. She was unconscious and her Glasgow coma scale (GCS) score was eight. Early vital signs were stable. Her first brain CT scan showed a subdural hematoma (SDH). One day after admission to ICU, her GCS decreased to five; hence, a control brain CT was performed. The brain CT scan showed a brain infarction. Six days after admission, her status worsened and her GCS dropped to three and her pupils became dilated bilaterally and unresponsive to light; she was pronounced dead.

DISCUSSION

We present an uncommon case of posttraumatic brain infarction and synchronous SDH.

Extracranial Carotid and Vertebral Artery Dissection: A Review

Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.

Incidence and outcome of vertebral artery dissection in trauma setting: analysis of national trauma data base

BACKGROUND

The natural history and epidemiological aspects of traumatic vertebral artery dissection (VAD) are not fully understood. We determined the prevalence of VAD and impact on outcome of patients with head and neck trauma.

METHODS

All the patients who were admitted with traumatic brain injury or head and neck trauma were identified by ICD-9-CM codes from the National Trauma Data Bank (NTDB), using data files from 2009 to 2010. NTDB represents one of the largest trauma databases and contains data from over 900 trauma centers across the United States. Presence of VAD was identified in these patients by using ICD-9-CM codes. Admission Glasgow Coma Scale (GCS) score, injury severity score (ISS), in-hospital complications, and treatment outcome were compared between patients with and without VAD.

RESULTS

A total of 84 VAD patients were identified which comprised 0.01 % of all patients admitted with head and neck trauma. The mean age (in years) for patients with VAD was significantly higher than patients without dissection [46 (95 % CI 41-50) vs. 41.3 (95 % CI 41.2-41.4); p = 0.003]. The proportion of patients presenting with GCS score <9 was significantly higher in patients with VAD (31 vs. 12 %, p < 0.0001). The rate of cervical vertebral fracture was significantly higher in patients with VAD (71 vs. 11 %, p < 0.0001). Patients with VAD had higher rates of in-hospital stroke than patients without dissection (5 vs. 0.2 %, p < 0.0001). Numbers of ICU days, ventilator days, and hospital length of stays were all significantly higher in patients with VAD. These differences remained significant after adjusting for the demographics, admission GCS score, and ISS (p < 0.0001). A total of 7 % (N = 6) of the patients with VAD received endovascular treatment and there was no in-hospital stroke in these patients. Patients with VAD had a higher chance of discharge to nursing facilities in comparison to head trauma patients without VAD (OR: 2.1; 95 % CI 1.4-3.5; p < 0.0001).

CONCLUSION

Although infrequent, VAD in head and neck trauma is associated with higher rates of in-hospital stroke and longer length of ICU stay and total hospital stay. Early diagnosis and endovascular treatment may be an alternative option to reduce the rate of in-hospital stroke in these patients.

Ischemic stroke after cervical spine injury: analysis of 11,005 patients using the Japanese Diagnosis Procedure Combination database

BACKGROUND CONTEXT

The incidence and relevant risk of ischemic stroke after cervical spine trauma remain unknown.

PURPOSE

To examine the incidence of ischemic stroke during hospitalization in patients with cervical spine injury, and analyze the impact of different types of cervical spine injuries on the occurrence of ischemic stroke.

STUDY DESIGN

Retrospective analysis of data abstracted from the Diagnosis Procedure Combination database, a nationally representative database in Japan.

PATIENT SAMPLE

We included all patients hospitalized for any of the following traumas: fracture of cervical spine (International Classification of Diseases, 10th Revision codes: S120, S121, S122, S127, S129); dislocation of cervical spine (S131, S133); and cervical spinal cord injury (SCI) (S141).

OUTCOME MEASURES

Outcome measures included all-cause in-hospital mortality and incidence of ischemic stroke (I63) during hospitalization.

METHODS

We analyzed the effects of age, sex, comorbidities, smoking status, spinal surgery, consciousness level at admission, and type of cervical spine injury on outcomes.

RESULTS

We identified 11,005 patients with cervical spine injury (8,031 men, 2,974 women; mean [standard deviation] age, 63.5 [18] years). According to the types of cervical spine injury, we stratified the patients into three groups: cervical fracture and/or dislocation without SCI (2,363 patients); cervical fracture and/or dislocation associated with SCI (1,283 patients); and cervical SCI without fracture and/or dislocation (7,359 patients). Overall, ischemic stroke occurred in 115 (1.0%) patients during hospitalization (median length of stay, 26 days). In-hospital death occurred in 456 (4.1%) patients. Multivariate analyses showed that ischemic stroke after cervical spine injury was significantly associated with age, diabetes, and consciousness level at admission. The highest in-hospital mortality was observed in patients with cervical fracture and/or dislocation associated with SCI (7.6%), followed by cervical SCI without fracture and/or dislocation (4.0%), and cervical fracture and/or dislocation without SCI (2.6%). Unlike mortality, risks of stroke did not vary significantly among the three groups.

CONCLUSIONS

This analysis revealed that ischemic stroke after cervical spine injury was not uncommon and was associated with increased mortality and morbidity. Occurrence of ischemic stroke was significantly associated with age, comorbidities such as diabetes, and consciousness level at admission, but not with the type of spine injury.

Traumatic Dissection of Four Brain-Supplying Arteries without Neurologic Deficit

Study Design Case report and review of the literature. Objectives Case report of a traumatic dissection of all major brain-supplying arteries resulting from a horseback-riding accident. Overview of the literature on diagnostic and therapeutic recommendations. Methods Case presentation. For the discussion, handpicked articles and PubMed database research with the keywords "dissection," "vertebral artery," "spine trauma," "computed tomography," "magnetic resonance imaging," and "angiography" were used. Results Despite high-energy induced acute lesion of all four cervical arteries, this 45-year-old patient did not demonstrate signs of microemboli nor suffer from stroke. Conclusion In case of high-energy trauma of the head and/or the neck, emergency physicians must consider traumatic cervical artery dissection (TCAD). Thus, emergency care algorithms should routinely include computed tomography angiography and magnetic resonance imaging. Although the incidence of TCAD-induced stroke is low, antiplatelet therapy is recommended in the presence of TCAD.

Clinical and radiological outcomes following traumatic Grade 1 and 2 vertebral artery injuries: a 10-year retrospective analysis from a Level 1 trauma center

Object

Screening of blunt vertebral artery (VA) injuries has increased since research has shown that they occur at a higher incidence than originally reported. Grade 1 and 2 injuries are the most common form of blunt VA injury. Proper screening, management, and follow-up of these injuries remain controversial. In this report, imaging, progression, treatment, and outcomes of Grade 1 and 2 blunt VA injuries were analyzed to better define their natural history and to establish a rational management plan based upon their risk of progression and cerebral infarct.

Methods

A retrospective review of all blunt traumatic carotid artery and VA injuries from December 2003 to April 2013 was performed. For the purposes of this report, focus was given to Grade 1 and 2 VA injuries. Grade 1 injuries were defined as a vessel lumen stenosis of less than 25%, and Grade 2 injuries were defined as vessel lumen stenosis between 25% and 50%. Demographic information, radiological imaging, number of images performed per individual, length of radiological follow-up, radiological outcome at the end of follow-up, treatment provided, and documentation of stroke or transient ischemic attack were recorded.

Results

One hundred eighty-seven Grade 1 and 2 VA injuries in 143 patients were identified. Of these 143 patients, 120 with 152 Grade 1 or 2 blunt VA injuries were available for follow-up. The mean duration of follow-up was 40 days. Repeat imaging showed that 148 (97.4%) Grade 1 or 2 blunt VA injuries were stable, improved, or resolved on final follow-up imaging. Seventy-nine patients (66%) were treated with aspirin, whereas 35 patients (29%) received no treatment. The remaining patients were treated with other antiplatelet agents or anticoagulant medication. Neuroimaging demonstrated 2 cases (1.7%) with posterior circulation infarcts that were believed to be related to their blunt VA injuries, both of which occurred during the initial hospitalization and within the first 4 days after injury.

Conclusions

Although follow-up imaging showed progressive worsening without radiological improvement in only a small number of patients with low-grade blunt VA injuries, these findings did not correlate with adverse clinical outcome. The posttraumatic cerebral infarction rate of 1.7% may be overestimated, and the use of acetylsalicylic acid or other antiplatelet or anticoagulant medication did not correlate with radiological changes or rate of cerebral infarction. While these data suggest the possibility that these low-grade VA injuries may not require treatment or follow-up, future prospective studies are needed to make conclusive changes related to management.

Closed manual reduction maneuver of atlantoaxial rotatory dislocation in pediatric age

PURPOSE

The purposes of this study were to characterize the clinical and radiological features of type 1 and type 2 atlantoaxial rotatory dislocations (AARD) and to evaluate the outcome of the manual reduction maneuver for these types of dislocations in pediatric patients.

METHODS

This study considered 12 pediatric patients with AARD who were treated between January 2003 and March 2013. The diagnosis was established by clinical findings and 3D-CT. All of the patients were treated by closed manual reduction and then a cervical orthosis was performed. All of the patients were followed up at regular intervals.

RESULTS

The causes of the AARD were trauma (91.67 %) and infection (8.33 %). The time between onset of symptoms and admission to the hospital ranged from 16 days to 6 months. In radiological evaluation, the mean rotational angulation of the patients was 30.58°. The 3D-CT examination showed that six patients (50 %) had type 1 dislocation and six patients (50 %) had type 2 dislocation. All of the patients were treated by closed manual reduction and then a cervical orthosis was performed. For 11 patients (91.67 %), dislocation was successfully reducted and maintained. One patient (8.33 %) underwent surgery, following recurrence of the second closed reduction maneuver.

CONCLUSION

This preceding treatment method has successfully produced a fast and recurrence-free alignment on all except one of our patients. This technique can be a useful treatment alternative in carefully selected AARD cases. Future research is encouraged to improve decision making in the application of this treatment method and provide additional validation of the current findings.

Vertebral artery dissection associated with generalized convulsive seizures: a case report

A 46-year-old male with juvenile myoclonic epilepsy was admitted to the neurological department for convulsive seizures just after lamotrigine was discontinued. On admission he was awake but had a right-sided hemiparesis with Babinski sign and ataxic finger-nose test on the left side. An MR scan showed a left-sided pontine infarction, an infarct in the left cerebellar hemisphere and a right vertebral artery dissection (VAD). The patient was treated with heparin and an oral anticoagulant for 6 months. Recovery of neurologic function was excellent. In patients with symptoms of disturbances of posterior circulation after epileptic seizures, VAD should be considered.

Contemporary management of combat-related vertebral artery injuries

BACKGROUND

Vertebral artery injuries (VAIs) following cervical trauma are uncommon. Advances in imaging technology and emerging endovascular therapies have allowed for the improved diagnosis and treatment of VAIs. We aimed to examine the contemporary management of combat-related penetrating VAIs during current US military operations.

METHODS

A retrospective review was performed on US casualties with combat-related VAIs evacuated to a single military institution in the US from September 2001 to 2010 for definitive management. Casualty demographics, mechanism of injury, location and type of VAI, neurologic sequela, associated injuries, method of diagnosis, and therapeutic management were collected.

RESULTS

Eleven casualties with a mean age of 26 years (mean [SD] ISS, 18 [7.0]) were found to have VAIs from gunshot wounds (6, 55%) or blast fragments (5, 45%). Cervical spine fractures (8, 72%), facial fractures (5, 45%), and spinal cord injury (3, 27%) were not uncommon. One casualty experienced a posterior cerebellar and parietal infarcts. All injuries were evaluated with digital subtraction angiography, 64-slice multidetector row computed tomography, or both. Casualties were noted to have vertebral artery occlusion (4, 36%), pseudoaneurysms (5, 45%), dissection (1, 9%), or arteriovenous fistula (1, 9%), with most injuries occurring in the V2 segment (6, 55%). Pseudoaneurysms were treated with coiling or stent-assisted coiling. Of 11 casualties, 6 were managed nonoperatively, half of whom with anticoagulation or antiplatelet therapy.

CONCLUSION

VAIs are infrequent in modern combat operations, occurring in only 3% of casualties experiencing arterial injuries and are often incidentally discovered during the delayed secondary evaluation of penetrating face and neck injuries at higher echelons of care. One should have a high index of suspicious for a VAI in a casualty with concurrent cervical spine fractures. Endovascular therapies using coils and covered stents have expanded the management options and simplified the treatment of combat-related VAIs.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Cervical arterial injury after blunt trauma in children: characterization and advanced imaging

BACKGROUND

The incidence of cervical vascular injury (CVI) after blunt cervical trauma in children and adolescents is low. Potential harm from missed injury is high. Screening for CVI has increased with advances in noninvasive angiography, including computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). We attempt to characterize CVI in children and adolescents and evaluate the utility of advanced imaging in CVI screening in this patient population.

METHODS

Clinical and radiographic records of consecutive patients aged 4 to 18 years with blunt cervical spine trauma from 1998 to 2008 were reviewed. Patient demographics, injury pattern, neurological findings, and treatment were recorded.

RESULTS

Sixty-one patients were identified. Nineteen underwent screening to evaluate for CVI, including 12 males and 7 females, mean age 13.5 years. The most common mechanism of injury was motor vehicle collision (n=11). Seven patients underwent MRA, 7 CTA, 3 had both studies, and 2 had traditional angiography. Seven patients had CVI, with an overall incidence of 11.5%. High-risk criteria (fracture extension to transverse foramina, fracture/dislocations or severe subluxations, or C1-C3 injury) were associated with increased rates of CVI. Neurological injury was found in 12/19 patients screened and 6/7 patients with CVI. Two of 7 patients underwent anticoagulation due to documented CVI. No delayed-onset ischemic neurological events occurred.

CONCLUSIONS

After blunt cervical spine trauma, certain fracture patterns increase the risk of CVI. CVI is common, with a minimum incidence of 7/61 or >10% of pediatric patients with blunt cervical spine injury. Over 1/4 of patients studied on the basis of high-risk criteria had injury. Advanced imaging with noninvasive angiography (CTA/MRA) should be strongly considered in pediatric patients with cervical spine trauma. The presence of CVI may prompt a change in management.

LEVEL OF EVIDENCE

Level IV-retrospective diagnostic study.

[Traumatic dissection of the internal carotid artery following whiplash injury. Diagnostic workup and therapy of an often overlooked but potentially dangerous additional vascular lesion]

We report on the case of a 33-year-old male patient who was brought to the emergency room of our hospital after suffering a high-energy trauma due to an automobile accident. Besides a scaphoid fracture there were no signs of any neurological deficits. After several hours without clinical symptoms the patient developed dysarthria as the first manifestation of local cerebral ischemia based on a traumatic dissection of the internal carotid artery. Under systemic high-dose heparin therapy, fast and complete remission of all neurological disorders could be achieved. In the course of time a dissecting aneurysm developed. Temporary anticoagulation with phenprocoumon was started in the meantime and no further complications have appeared up to now. Besides presenting this absorbing case, this article highlights the diagnostic and therapeutic regime in cases of a traumatic dissection of supra-aortal arteries for rapid and adequate management of this rare but potentially dangerous complication.

A case of traumatic intracranial vertebral artery injury presenting with life-threatening symptoms

Traumatic intracranial vertebral artery injury is a relatively rare but potentially fatal disease. We present a case of a 63-year-old man who presented with sudden onset of loss of consciousness after hitting his head. After immediate resuscitation, he showed quadriplegia and absence of spontaneous breathing. Brain and cervical spine magnetic resonance imaging revealed an atlantoaxial subluxation, fractured C2 odontoid process, left vertebral artery occlusion, and bilateral extensive ischemia in the medulla oblongata and high cervical spinal cord. Digital subtraction angiography demonstrated left vertebral artery dissection just below the level of vertebral body C2.

Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures

BACKGROUND

It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). We sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns.

METHODS

We performed a retrospective study in patients with CSfx who underwent evaluation for BCVI. The presence of recognized CS risk factors for BCVI and other risk factors (Glasgow coma score ≤ 8, skull-based fracture, complex facial fractures, soft-tissue neck injury) were reviewed. Patients were divided into 2 groups based on the presence/absence of risk factors.

RESULTS

A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%).

CONCLUSIONS

We propose that all CS fracture patterns warrant screening for BCVI.

Effect of heparin following cervical spinal cord injuries in rats

BACKGROUND

Risks of neurological deterioration after heparin administration following cervical spinal cord injury (SCI) in humans are unknown.

OBJECTIVE

To elucidate the safety of heparin following cervical SCI and investigate its potential neuroprotectant role.

METHODS

Sixty-two Sprague Dawley adult rats were subjected to mild (0.6 mm), moderate (0.9 mm), or severe (1.2 mm) C7-SCI. At each injury severity, intravenous heparin or saline was administered for 72 hours following SCI. Behavioral tests (Basso, Beattie, Bresnahan scores, Hargreave's) were performed before killing the rats at week 7. Half of the rats were killed at day 3, and the remainder at week 7 after SCI. Immunohistochemistry, Western blot analysis, and axonal retrograde tracing were conducted at both times.

RESULTS

Subpial hemorrhage was greater in heparin-treated animals compared with controls at all severities of SCI day 3 after injury. Counterintuitively, intraparencyhmal hemorrhage was minimal in the lesion epicenter following mild SCI in the heparin-treated animals compared with controls. India ink perfusion revealed greater preservation of microcirculation in heparin-treated animals compared with a reduction in control animals. A decrease in spinal cord perfusion correlated directly with an increase in hypoxia-inducible factor-1α expression. There was significant gray matter sparing, but no change in white matter volume after heparin treatment at week 7 in the mild SCI group. Beneficial effects on hemorrhagic volume, axon sparing, and functional recovery following heparin treatment were not observed in the moderate or severe SCI group.

CONCLUSION

Heparin treatment following SCI is safe at all degrees of injury. Heparin decreases platelet aggregation and microvascular occlusion, providing a potential neuroprotective effect following mild SCI.

Lesson of the month (1). Homonymous left hemianopia secondary to traumatic extracranial vertebral artery dissection

This lesson reports the case of a 32-year-old female presenting with left-sided homonymous hemianopia after a road traffic accident. A diagnosis of vertebral artery dissection (VAD) was missed at presentation after an initial computed tomography head scan was normal. Later, VAD was confirmed on neck magnetic resonance imaging. VAD is an uncommon cause of stroke in the young and, to date, there are no current emergency guidelines available for the management of patients with the condition.

Fatal outcome after brain stem infarction related to bilateral vertebral artery occlusion - case report of a detrimental complication of cervical spine trauma

BACKGROUND

Vertebral artery injury (VAI) after blunt cervical trauma occurs more frequently than historically believed. The symptoms due to vertebral artery (VA) occlusion usually manifest within the first 24 hours after trauma. Misdiagnosed VAI or delay in diagnosis has been reported to cause acute deterioration of previously conscious and neurologically intact patients.

CASE PRESENTATION

A 67 year-old male was involved in a motor vehicle crash (MVC) sustaining multiple injuries. Initial evaluation by the emergency medical response team revealed that he was alert, oriented, and neurologically intact. He was transferred to the local hospital where cervical spine computed tomography (CT) revealed several abnormalities. Distraction and subluxation was present at C5-C6 and a comminuted fracture of the left lateral mass of C6 with violation of the transverse foramen was noted. Unavailability of a spine specialist prompted the patient's transfer to an area medical center equipped with spine care capabilities. After arrival, the patient became unresponsive and neurological deficits were noted. His continued deterioration prompted yet another transfer to our Level 1 regional trauma center. A repeat cervical spine CT at our institution revealed significantly worsened subluxation at C5-C6. CT angiogram also revealed complete occlusion of bilateral VA. The following day, a repeat CT of the head revealed brain stem infarction due to bilateral VA occlusion. Shortly following, the patient was diagnosed with brain death and care was withdrawn.

CONCLUSION

Brain stem infarction secondary to bilateral VA occlusion following cervical spine trauma resulted in fatal outcome. Prompt imaging evaluation is necessary to assess for VAI in cervical trauma cases with facet joint subluxation/dislocation or transverse foramen fracture so that treatment is not delayed. Additionally, multiple transportation events are risk factors for worsening when unstable cervical injuries are present. Close attention to proper immobilization and neck position depending on the mechanism of injury is mandatory.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Vertebral artery injury after cervical spine trauma: A prospective study using computed tomographic angiography

Background:

Although the vertebral artery injuries (VAI) associated with cervical spine trauma are usually clinically occult, they may cause fatal ischemic damage to the brain stem and cerebellum.

Methods:

We performed a prospective study using computed tomographic angiography (CTA) to determine the frequency of VAI associated with cervical spine injuries and investigate the clinical and radiological characteristics. Between January 2005 and August 2007, 99 consecutive patients with cervical spine fractures and/or dislocations were prospectively evaluated for patency of the VA, using the CTA, at the time of injury.

Results:

Complete disruption of blood flow through the VA was demonstrated in seven patients with unilateral occlusion (7.1%). There were four men and three women with a mean age of 43 (range, 33-55 years). Unilateral occlusion of the right vertebral artery occurred in four patients and of the left in three. Regarding the cervical injury type, two cases were cervical burst fractures (C6 and C7), two had C4-5 fracture/dislocations, two had a unilateral transverse foraminal fracture, and one had dens type III fracture. All patients presented with good patency of the contralateral VA. None of the patients developed secondary neurological deterioration due to vertebrobasilar ischemia during the follow-up period with a mean duration of 23 months.

Conclusions:

VAI should be suspected in patients with cervical trauma that have cervical spine fractures and/or dislocations or transverse foramen fractures. CTA was useful as a rapid diagnostic method for ruling out VAI after cervical spine trauma.

Fatal basilar thrombosis possibly related to minor cervical trauma: a case report

Background. Basilar thrombosis is a potentially fatal event, whose traumatic etiology has been repeatedly stated. Methods. We performed the autopsy and the microscopic examination of the brain stem structures from an individual, whose sudden death raised logical suspicions regarding the causative factor. Results. The brain was swollen and clearly hyperemic; a massive basilar thrombus with complete occlusion of the median segment of the basilar artery was macroscopically seen. The brainstem showed an infarcted zone in the pons, with secondary hemorrhagic changes, mainly in the form of multiple petechial hemorrhages. Pontine arteries showed extensive alterations, mainly in the form of severed endothelium, which suggested a thrombotic-traumatic mechanism as the main etiological factor. Conclusions. Minor injuries, such as slight whiplashes, abrupt neck movements, neck trauma related to the slowing down of the vehicles, and critical neck positioning, can all of them explain a thrombotic event in the basilar artery, leading to a fatal occurrence. Other risk factors may obviously concur, but their importance seems unclear.

Postdischarge Outcomes of Blunt Cerebrovascular Injuries

A retrospective review was conducted to assess outcomes of blunt cerebrovascular injuries (BCVIs) diagnosed in a 14-month period at a level-1 trauma center and evaluated postdischarge at a single vascular practice. Twenty-nine patients with 34 BCVIs (10 carotid; 24 vertebral) were admitted. Eleven (37.9%) patients were treated with combined anticoagulation and antiplatelet therapy, 9 (31.0%) with anticoagulation, and 4 (13.8%) with antiplatelets. Five (17.2%) patients underwent observation. Seventeen (58.6%) patients (19 injuries) returned for follow-up evaluation. At a mean follow-up of 9.2 weeks, all patients had normal neurological examinations with no complications. Sixteen (84.2%) BCVIs resolved. Anticoagulation and antiplatelet therapies were equally effective in preventing cerebral infarction. Although the majority of lesions resolve, BCVIs have the ability to progress and often require surgical intervention. Routine follow-up after discharge is warranted for all BCVIs and should include repeat computed tomography angiography (CTA) with bilateral carotid/vertebral duplex ultrasound (US) as a physiological test.

Imaging of traumatic arterial injuries in the neck with an emphasis on CTA

Arterial injuries in the neck may be secondary to blunt or penetrating trauma. Because of clinical difficulties in early identification of these injuries as well as their potentially catastrophic consequences, imaging is indispensible in the diagnosis of arterial injuries in the neck. Computed tomography angiography (CTA) has become the initial study of choice in management of these patients. We review the clinical and imaging features of vascular injuries of the neck with special emphasis on CTA.