History: 26-year-old male presented to the trauma center following a motor vehicle collision.
Exam: Awake and alert, intubated
Sensation is intact to T4 dermatome
Motor strength is 0/5 in all extremities
The patient is taken to the operating room for emergent decompression and fusion, with a planned second stage posterior approach to be performed later.
Postoperatively he remained intubated and had bicep movement graded at 2/5 on the left and 3/5 on the right.
Preop and postop CT images of the spine are shown. A follow up head CT was performed to check the status of a small parietal contusion.
1. What is the likely cause of the imaging finding on the head CT?
2. What is the next step in treatment for the finding on the CT scan of the brain?
3. Which of the following is an indication for endovascular treatment of vertebral artery injury?
4. Which describes you?
5. I practice in one of the following locations.
7. Approximately what percentage of patients with Grade IV vertebral artery injuries will develop a stroke in a related territory?
This patient has suffered a spinal cord injury and bilateral vertebral artery occlusions (Grade IV vertebral artery injury) demonstrated on the accompanying CTA.
Question 1- Correct answer: A. Vascular insult The follow-up CT scan demonstrates an evolving infarct in the region of the posterior inferior cerebellar artery. The CT is not consistent with neoplasm, and increased intracranial pressure is unlikely to cause this finding.
Question 2- Correct answer: D. Anticoagulation. The next step is anticoagulation with heparin. An MRI is not necessarily incorrect, however in this case the cause of the CT finding is reasonably certain.
Question 3- Correct answer B. Progressive neurological deficit. Endovascular intervention should be considered in the presence of a progressive neurological deficit despite the usage of anticoagulation. It may also be considered in the presence of developing pseudoaneurysm.
Question 4- Correct answer: D. 44% The risk of infarct in this type of injury is approximately 44%.
The Denver Criteria help define patients at risk for blunt cerebrovascular injury and has been shown to improve recognition of injuries and decrease unnecessary screening CT scans.
Risk factors include-
Petrous bone fracture, diffuse axonal injury with Glasgow coma score <6, cervical spine fracture especially with fracture of C1 to C3 and fracture through the foramen transversarium, cervical spine fracture with subluxation or rotational component, Lefort II or III facial fractures, basilar skull fracture with carotid canal involvement, and near hanging with anoxic injury.
Signs and symptoms include-
arterial hemorrhage, cervical bruit in patient <50 years of age, expanding cervical hematoma, focal neurologic deficit, neurologic exam incongruous with head CT, and stroke on secondary CT scan.
- Drain JP1, Weinberg DS, Ramey JS, Moore TA, Vallier HA. Indications for CT-Angiography of the Vertebral Arteries After Trauma. Spine (Phila Pa 1976). 2018 May 1;43(9):E520-E524.
- Beliaev AM, Barber PA, Marshall RJ, Civil I. Denver screening protocol for blunt cerebrovascular injury reduces the use of multi-detector computed tomography angiography. ANZ J Surg. 2014 Jun;84(6):429-32.
- Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography.
- Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma. 2003 Nov;55(5):811-3.
- Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Elliott JP, Burch JM.
- Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999. Dec;178(6): 517-22.
- Biffl WL, Moore EE, Ryu RK, Offner PJ, Novak Z, Coldwell DM, Franciose RJ, Burch JM.The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg. 1998 Oct;228(4):462-70.