Blunt injuries to the extracranial cerebral vessels associated with spine fractures

Bilateral cerebellar and brain stem infarction resulting from vertebral artery injury following cervical trauma without radiographic damage of the spinal column: a case report

Vertebral artery injury can be a complication of cervical spine injury. Although most cases are asymptomatic, the rare case progresses to severe neurological impairment and fatal outcomes. We experienced a case of bilateral cerebellar and brain stem infarction with fatal outcome resulting from vertebral artery injury associated with cervical spine trauma. A 69-year-old male was admitted to our hospital because of tetraplegia after falling down the stairs and hitting his head on the floor. Marked bony damage of the cervical spine was not apparent on radiographs and CT scans, so the injury was initially considered to be a cervical cord injury without bony damage. However, an intensity change in the intervertebral disc at C5/C6, and a ventral epidural hematoma were observed on MRI. A CT angiogram of the neck showed the right vertebral artery was completely occluded at the C4 level of the spine. Forty-eight hours after injury, the patient lapsed into drowsy consciousness. The cranial CT scan showed a massive low-density area in the bilateral cerebellar hemispheres and brain stem. Anticoagulation was initiated after a diagnosis of the right vertebral artery injury, but the patient developed bilateral cerebellar and brain stem infarction. The patient's brain herniation progressed and the patient died 52 h after injury. We considered that not only anticoagulation but also treatment for thrombosis would have been needed to prevent cranial embolism. We fully realize that early and appropriate treatment are essential to improve the treatment results, and constructing a medical system with a team of orthopedists, radiologists, and neurosurgeons is also very important.

The incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures: a 10-year experience at an academic medical center

STUDY DESIGN

Retrospective medical record review.

OBJECTIVE

The purpose of this study was to describe the incidence of other injuries that commonly occur in conjunction with cervical spine fractures and dislocations.

SUMMARY OF BACKGROUND DATA

Cervical spine fractures are often associated with other significant traumatic conditions, which may also require prompt diagnosis and management. However, the relative incidences of the injuries that occur in conjunction with various cervical spine fractures have not been well documented.

METHODS

The radiographic reports of all patients who underwent CT scans of the cervical spine at a single level 1 trauma center over a 10-year period were reviewed. The medical records of individuals with acute, nonpenetrating fractures of the cervical spine were further assessed for any associated traumatic pathology including noncontiguous spine injuries and those affecting other organ systems (i.e., head and neck, intrathoracic, intra-abdominal/pelvic, and nonspinal orthopedic disorders).

RESULTS

A total of 13,896 CT scans of the cervical spine were performed during this 10-year period of which 492 revealed acute fractures and/or dislocations. Of these subjects, 60% had sustained at least one additional injury. Overall, 57% were noted to have extraspinal injuries (34% head and neck, 17% intrathoracic, 10% intra-abdominal/pelvic, and 30% nonspinal orthopedic conditions) and noncontiguous spinal trauma was present in 19% of these cases (8% cervical injuries, 8% thoracic, and 6% lumbar). In general, the rates of associated injuries observed with occipital condyle and C7 fractures were significantly higher than those recorded for other cervical segments.

CONCLUSION

For patients with a known history of cervical spine trauma, the frequencies of associated injuries were similar across all levels of the cervical spine with the exception of the injuries to the craniocervical junctions. In practice, this means that injuries to the cervical spine can likely be grouped together when considering other possible associated injuries. Further elucidation of these injury patterns will likely be useful for facilitating the expedient evaluation and proper management of these individuals.

Bilateral blunt carotid artery trauma associated with a double lower thoracic spine fracture: a case report and review of the literature

Background

A 26 year old female suffering from a double fracture of the lower thoracic spine, as a result of a car accident, was referred to the Spine Unit of our Department. No neurological deficit was detected during clinical examination. Due to the fracture's instability, posterior stabilization was performed.

Case presentation

Postoperatively, the patient presented a decrease in Glasgow Coma Scale (GCS) combined with motor and sensory deficit from the right upper and lower extremities. Cerebral ischemia was diagnosed, secondary to distal emboli from the right and left internal carotid arteries bilaterally.

Conclusion

Patients' neurological deficits eventually resolved after conservative treatment and anticoagulation therapy.

Vertebral artery injury after blunt cervical trauma: an update

BACKGROUND

Vertebral artery injury (VAI) after blunt cervical trauma has been considered to be rare. The incidence of VAI has increased dramatically within the last decade after a heightened awareness of this entity on the part of spine surgeons. Diagnostic or therapeutic guidelines for VAI have not been established fully, however.

METHODS

A review of the literature published between 1990 and 2004 was conducted.

RESULTS

The incidence of VAI among total blunt trauma admissions ranged from 0.20% to 0.77%. Most VAI patients remained asymptomatic, but sudden unexpected deterioration was often reported. Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. Digital subtraction angiography was the most sensitive imaging study, but because of invasiveness, its role as a screening study remained questionable. Neuroradiological intervention was used successfully to treat hemorrhagic VAI and progressing vertebrobasilar stroke. Systemic anticoagulation with heparin was the preferred treatment for mild ischemia. Treatment of asymptomatic patients has been controversial because the natural history of VAI has not been elucidated. Prophylactic anticoagulation with heparin or the use of antiplatelet agents was advocated in recent studies.

CONCLUSIONS

Preemptive treatment may be reasonable in selected patients considering the devastating potentials of VAI. The potential risks of heparin or antiplatelet agents in relation to early cervical spine surgery have not been addressed fully, however, and spine surgeons have to weigh the risk and benefit of such treatment cautiously.

A lateral mass fracture of C1 associated with left vertebral artery and mid-basilar artery occlusion

Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.

Vertebral artery occlusion associated with cervical spine trauma. A prospective analysis

STUDY DESIGN

Radiographs and charts of 61 patients sustaining cervical spine trauma were studied prospectively to determine the incidence of vertebral artery injuries and possible correlative factors. Statistical analysis was conducted using chi-square testing of a two-way classification system.

OBJECTIVES

To elucidate the incidence of vertebral artery injuries associated with cervical spine trauma, and to determine the value of various factors in predicting the existence of a vertebral artery injury.

SUMMARY OF BACKGROUND DATA

During a 7-month period, 61 patients (41 male patients, 20 female; average age, 40.3 years) with cervical spine trauma were studied.

METHODS

All patients admitted to the authors' hospital with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of their cervical spine. All magnetic resonance angiographies were examined for vertebral artery injury. Data on demographics and the injury were recorded.

RESULTS

Complete disruption of blood flow through the vertebral artery was demonstrated by magnetic resonance angiography in 12 of the 61 patients (19.7%). Ten of the 12 patients (83%) had either flexion distraction or flexion compression injuries. Age, sex, mechanism of injury, neurologic impairment, and associated injuries were not statistically significant in predicting the presence of a vertebral vessel occlusion.

CONCLUSION

The findings in this study may support the need for vertebral vessel evaluation in selective patients, particularly those with flexion injuries and with neurologic symptoms consistent with vertebral artery insufficiency syndrome that do not correlate with the presenting bone and soft-tissue injuries.

Carotid and vertebral artery occlusion after blunt cervical injury: the role of MR angiography in early diagnosis

The early diagnosis of cervical vascular trauma is critical in the prevention of cerebral ischemia. Traumatic blunt carotid or vertebral artery dissection is rare and frequently associated with other injuries. Diagnosis is often delayed, limiting treatment options and contributing to a poor outcome. The clinical findings and investigation of 14 patients are presented with special reference to the last three who had magnetic resonance imaging angiography. Treatment options are discussed and it is suggested that with modern methods of investigation and management, the prognosis of this condition may be improved.

Vertebral artery injury associated with a Jefferson fracture

BACKGROUND

The evaluation and treatment of Jefferson fractures, a burst fracture of the ring of Cl, has been well documented in the medical literature. Vertebral artery injury associated with a Jefferson fracture is very rare.

METHODS

The case study technique was used to summarize the case. Review of the literature was performed to discuss the case. Retrospective chart review of the 174 patients with cervical fractures admitted to St. Michael's Hospital from 1989-1994 was also performed.

RESULTS

The case of a patient with a Jefferson fracture, with bilateral lateral displacement of the lateral masses causing bilateral vertebral artery occlusions resulting in a lateral medullary and cerebellar infarction is reported. A review of the literature is provided.

CONCLUSION

A high index of suspicion for this injury is paramount, especially in patients with multiple trauma, where the diagnosis of Jefferson fractures can be delayed.