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concerning extension…

July 30, 2013 By Christopher Partyka Leave a Comment

the case.

You receive a BAT call about a 31 year-old male who has come off his bicycle after running into a stationary car at ~30 km/hour. Bystanders report that he was thrown 3-5m and had a loss of consciousness of ~3 minutes without witnessed seizure activity.

On arrival, he is alert but confused (GCS E4 V4 M6). He is haemodynamically normal with the only injuries noted on primary survey being a significant left forehead haematoma and midline cervical tenderness at C5-7. His upper and lower limb neurological assessment, as well as his cranial nerve exam is normal.

You order him a CT brain and cervical spine as part of his trauma assessment…

CTB01CTB02CTB03CTB04

CTAxialC-Sp05CTAxialC-Sp06CTAxialC-Sp08CTAxialC-Sp09

What are the significant findings here ??

The CT brain shows significant left frontal contusions.

CT C-spine shows a fracture of C6 involving the left facet joint with extension into the transverse foramen.

Here are the more detailed CT’s…

httpv://www.youtube.com/watch?v=vUZtH38sG1o

httpv://www.youtube.com/watch?v=31eRTgX87aw

What about the vertebral artery ??

Good question.

Vertebral Artery Injury.

    • Occurs in ~0.1% of trauma patients (includes carotid & vertebral vessel injury).
        • ~1% of asymptomatic patients of blunt trauma & up to 2.7% of patients w/ Injury Severity Score ≥16.
        • >70% of vertebral artery injuries are associated w/ cervical spine fractures.
        • Majority are diagnosed after the development of secondary CNS ischaemia.
    • Mechanism.
        • May follow mild events such as sudden rotation or hyperextension of neck.
        • Can occur from yoga, coughing or vomiting.
        • Seen more frequently in people with underlying pathology of vessel wall (eg. connective tissue disorders).
    • The vertebral arteries are susceptible to mechanical injury due to relationship to neighbouring bony structures & ligaments.
        • Most susceptible to injury at the entrance into the transverse foramen (C6) & at C1-2.
        • Occurs due to shearing forces at junctions between fixed & mobile segments.
        • Intimal disruption may lead to complete thrombotic occlusion, subintimal haematoma, dissection and pseudoaneurysm formation.
    • Diagnosis is often delayed as 17-35% of patients do not develop neurological signs for > 24 hours after injury.
        • Concomitant intoxication & head-injury can further delay diagnosis.
    • Mortality 8-18%.

Who should be screened for blunt VAI ?

Patients of significant blunt head trauma with;

    • GCS ≤ 8
    • Basilar skull fracture
    • Diffuse axonal injury
    • Le Fort II or III facial fractures
    • Facial haemorrhage
    • Expanding neck haematoma
    • Attempted hanging with anoxic brain injury
    • Focal neurological signs that cannot be explained by the CT-brain.

Which patterns of cervical spine fracture predict blunt VAI ?

C-spine fracture:

    • C1-C3
    • Extension into foramen transversarium
    • Subluxation or rotational component

How do we screen for VAI ?

    • Catheter-based angiography (DSA)
        • Remains ‘gold standard’.
        • Risks include embolism, bleeding & reaction to contrast.
    • CT-angiography
        • Multislice (8 or greater) just as good as formal angio.
        • Sn 97.7%, Sp 100% – compared to catheter angiography.
    • MRI
        • Accurately diagnoses dissection, without risks associated with conventional angiography.
        • Provides other information also [eg. cerebral ischaemia, cord contusion, spinal ligamentous injury, size of thrombus].
    • Ultrasound
        • Not adequate for screening. Poor sensitivity.

The story continues…

Given the mechanism of injury and the fracture through the transverse foramen, you order him a carotid and vertebral CT angiogram…

Angio04 Angio05 Angio02

… which demonstrates interruption of flow in the left vertebral artery consistent with dissection.

How should these be treated ?!?

Generally based on the following Biffl et al Grading System…

VAI Grading System

    • Grade I & II injuries should be treated w/ antithrombotic agents such as heparin or aspirin.
        • Heparin & antiplatelet therapy can be used with equivalent results.
        • Heparin started w/out a bolus.
        • Warfarin therapy should follow w/ target INR of 2-3 (for 3-6 months).
    • Grade III injuries rarely resolve with observation or heparinisation.
        • Invasive therapy should be considered.
    • Repeat imaging (CT-A) should be performed for grades I-III injuries at 7-10 days post-injury.

References.

  1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  2. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
  3. Bromberg WJ et al. Blunt cerebrovascular injury practice management guidelines: The eastern association for the surgery of trauma. J Trauma. 2010; 68; 471-477
  4. Cothren CC et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma. 2003 Nov;55(5):811-3.
  5. Mueller CA et al. Vertebral artery injuries following cervical spine trauma: a prospective observational study. Eur Spine J. 2011 Dec;20(12):2202-9.
  6. Desouza RM et al. Blunt traumatic vertebral artery injury: a clinical review. Eur Spine J. 2011 Sep;20(9):1405-16.
  7. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma. 1999;47:845– 853.

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Filed Under: #FOAM, Evidence, Interesting, Radiology, Spine, Trauma Tagged With: blunt vertebral artery injury, cervical spine fracture, CT angiography, foramen transversarium, posterior circulation stroke, screening, Trauma, Vertebral artery dissection

About Christopher Partyka

Emergency Doc; interested in ultrasound, retrieval & medical education - #FOAMed

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