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

Hiroyuki Yoshihara,Kathryn M Beauchamp,Yasuaki Harasaki,Philip F Stahel,Todd F Vanderheiden

doi:10.1186/1754-9493-5-18

Hiroyuki Yoshihara, Kathryn M Beauchamp + Show 3 more

Open Access

https://doi.org/10.1186/1754-9493-5-18

Copy DOI

Abstract

BackgroundVertebral 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 presentationA 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 Shortly following, the patient was diagnosed with brain death and care was withdrawn.ConclusionBrain stem infarction secondary to bilateral VA occlusion following cervical spine trauma resulted in fatal outcome.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.

Highlights

Vertebral artery injury (VAI) after blunt cervical trauma had previously been considered to be rare until clinical studies revealed data to the contrary [1,2]
Brain stem infarction secondary to bilateral vertebral artery (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

Summary

Conclusion

This patient died from brain stem infarction secondary to bilateral VA occlusion following blunt cervical spine trauma. Poor neck positioning, and improper immobilization seemed to result in worsened subluxation at the injured cervical segment This may have contributed to the rapid decline in this patient’s course from both a neurological and vascular standpoint. Multiple transportation events should be avoided in all possible scenarios and stable, proper immobilization with correct neck position depending on the mechanism of injury is necessary. These fundamental principles may enable prevention of secondary injury to the damaged cervical spine and the important vascular structures of this region. The authors declare no other competing interests related to this case report

Introduction

Findings