43 year old male injured in a motor vehicle crash in which his
car rolled over. The patient was first managed in a County hospital
and was transferred to our hospital (Level 1) 48hrs later. On
arrival in the emergency department he was fully conscious (Glasgow
Coma Score 15) and complaining of headache. Physical examination
revealed skin lesions on the left showlder and vertical nystagmus.
Lateral cervical spine X-ray film showed a C2 fracture, confirmed
on CT scan.
CT scan of the brain was suggestive
of cerebellar infarction and this was confirmed on magnetic resonance
At that point it was clear our
patient had an ipsilateral vertebral artery injury, thus we asked
for an MR angiography that reveals nonopacification of the left
vertebral artery consistent with occlusion. A neurosurgical consult
was warranted, the patient recived treatment with steroids and
cervical collar and finally nine days later was discharged without
dizziness or headache.
Karim Brohi (London, UK):
The association between cervical spine fractures and vertebral
artery injury is well documented, although the true incidence
of the condition and its significance remains unclear. Imaging
of the vertebral artery is not routine in cervical spine trauma,
so those case reports in the literature tend to report only those
patients presenting with neurologic deficits, as with this patient.
Four studies have prospectively evaluated cervical spine injuries
using conventional or magnetic resonance angiography. The incidence
of vertebral artery injury with cervical spine fracture ranged
between 24% and 46%. However only about one quarter of these patient
will have neurological deficits.
Young asymptomatic patients are
probably at low risk for neurologic sequelae of unilateral vertebral
artery injury due to the presence of a contralateral normal vertebral.
However older patients may be at increased risk if the contralateral
artery is already stenosed or occluded. Unlateral complete occlusion
is probably more innocent than a dissection or false aneurysm
as these injuries may be more likely to lead to distal embolization.
Magnetic resonance angiography is non-invasive and reputed to
have an accurracy of approximately 80%. However it may be less
sensitive than conventional angiography, and the role of duplex
ultrasound is also unclear.
Patients with cervical spine fracture
who have neurological deficits suggestive of vertebral artery
injury, or those with high-risk fractures (involving the foramen
transversarium) should undergo either conventional or magnetic
1. Giacobetti FB; Vaccaro AR; Bos Giacobetti
MA et al. 'Vertebral artery occlusion associated with cervical
spine trauma. A prospective analysis' Spine 1997;22:188-92
2. Willis BK, Greiner F, Orrison
WW et al. 'The incidence of vertebral artery injury after midcervical
spine fracture or subluxation' Neurosurgery 1994;34:435-442
D; Flanders A; Thomas C; Millar W. 'Vertebral artery injury
after acute cervical spine trauma: rate of occurrence as detected
by MR angiography and assessment of clinical consequences'
Am J Roentgenol 1995;164:443-447; discussion 448-449
SJ; Rossitch E Jr; Malek AM ' Detection of vertebral artery
injury after cervical spine trauma using magnetic resonance angiography'
J Trauma 1999;46:660-666
AR; Klein GR; Flanders AE et al. 'Long-term evaluation of vertebral
artery injuries following cervical spine trauma using magnetic
resonance angiography' Spine 1998;23:789-794; discussion 795
trauma.org (5:6) June 2000