Angiographic frequency of blunt cerebrovascular injury in patients with carotid canal or vertebral foramen fractures on multidetector CT

Vertebral artery dissection in acute cervical spine trauma

Objective:

The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST).

Methods:

A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD.

Results:

Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified.

Conclusion:

There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.

The Utility of Short-Interval Repeat Computed Tomography Angiogram After Blunt Cerebrovascular Injury in Adults

Introduction

Blunt cerebrovascular injury (BCVI) can lead to thromboembolic events. The necessity of short-interval noninvasive vascular imaging after the initial diagnosis is controversial. This retrospective cohort assesses the utility of short-interval computed tomography angiography (CTA) after an initial diagnosis of BCVI. 

Methods

We retrospectively reviewed patients with BCVI managed at our institution from 2016 to 2019 who underwent a short-interval (one to three weeks) repeat CTA after initial diagnosis. We excluded patients with age <18 years, penetrating injury, and previous neck irradiation. We collected baseline data and performed logistic regression to identify predictors of BCVI imaging outcomes. 

Results

The study cohort comprised 38 patients with a mean age of 45 years with 68% males. Motor vehicle crash (MVC) was the most common mechanism of 79% injury. Unilateral vertebral artery (VA) was the most common vessel that is 66% injured, and grade I 36% was the most common dissection on initial CTA. Grades III and IV dissection 33% were the most common in the short-interval CTA. Shift analysis showed a significant improvement in Biffl grades I on the short-interval CTA (p = 0.0001). Antiplatelet therapy or anticoagulation (AC) was administered to 82% of patients after the initial diagnosis. The rates of early (<2 weeks) and delayed (two weeks to three months) ischemia were 5% and 0%, respectively, and endovascular stenting was performed in 8%. 

Conclusion

BCVI grades I and II are more frequent than high-grade injuries. Short-interval non-invasive vascular imaging can detect changes of BCVI which can affect the management paradigm. It also can select patients who will benefit from endovascular intervention and avoid stroke. Besides, the short-interval non-invasive vascular imaging will not incur additional cost or increase exposure to radiation.

Best practice guidelines for blunt cerebrovascular injury (BCVI)

Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.

Neurologic complications of polytrauma

Neurologic complications in polytrauma can be classified by etiology and clinical manifestations: neurovascular, delirium, and spinal or neuromuscular problems. Neurovascular complications include ischemic strokes, intracranial hemorrhage, or the development of traumatic arteriovenous fistulae. Delirium and encephalopathy have a reported incidence of 67-92% in mechanically ventilated polytrauma patients. Causes include sedation, analgesia/pain, medications, sleep deprivation, postoperative state, toxic ingestions, withdrawal syndromes, organ system dysfunction, electrolyte/metabolic abnormalities, and infections. Rapid identification and treatment of the underlying cause are imperative. Benzodiazepines increase the risk of delirium, and alternative agents are preferred sedatives. Pharmacologic treatment of agitated delirium can be achieved with antipsychotics. Nonconvulsive seizures and status epilepticus are not uncommon in surgical/trauma intensive care unit (ICU) patients, require electroencephalography for diagnosis, and need timely management. Spinal cord ischemia is a known complication in patients with traumatic aortic dissections or blunt aortic injury requiring surgery. Thoracic endovascular aortic repair has reduced the paralysis rate. Neuromuscular complications include nerve and plexus injuries, and ICU-acquired weakness. In polytrauma, the neurologic examination is often confounded by pain, sedation, mechanical ventilation, and distracting injuries. Regular sedation pauses for examination and maintaining a high index of suspicion for neurologic complications are warranted, particularly because early diagnosis and management can improve outcomes.

Blunt cerebrovascular injuries in severe traumatic brain injury: incidence, risk factors, and evolution

OBJECTIVE Blunt cerebrovascular injuries (BCVIs) affect approximately 1% of patients with blunt trauma. An antithrombotic or anticoagulation therapy is recommended to prevent the occurrence or recurrence of neurovascular events. This treatment has to be carefully considered after severe traumatic brain injury (TBI), due to the risk of intracranial hemorrhage expansion. Thus, the physician in charge of the patient is confronted with a hemorrhagic and ischemic risk. The main objective of this study was to determine the incidence of BCVI after severe TBI. METHODS The authors conducted a prospective, observational, single-center study including all patients with severe TBI admitted in the trauma center. Diagnosis of BCVI was performed using a 64-channel multidetector CT. Characteristics of the patients, CT scan results, and outcomes were collected. A multivariate logistic regression model was developed to determine the risk factors of BCVI. Patients in whom BCVI was diagnosed were treated with systemic anticoagulation. RESULTS In total, 228 patients with severe TBI who were treated over a period of 7 years were included. The incidence of BCVI was 9.2%. The main risk factors were as follows: motorcycle crash (OR 8.2, 95% CI 1.9-34.8), fracture involving the carotid canal (OR 11.7, 95% CI 1.7-80.9), cervical spine injury (OR 13.5, 95% CI 3.1-59.4), thoracic trauma (OR 7.3, 95% CI 1.1-51.2), and hepatic lesion (OR 13.3, 95% CI 2.1-84.5). Among survivors, 82% of patients with BCVI received systemic anticoagulation therapy, beginning at a median of Day 1.5. The overall stroke rate was 19%. One patient had an intracranial hemorrhagic complication. CONCLUSIONS Blunt cerebrovascular injuries are frequent after severe TBI (incidence 9.2%). The main risk factors are high-velocity lesions and injuries near cervical arteries.

Detailed description of anatomy of the fracture line in hangman's injury: a retrospective observational study on motor vehicle accident victims

OBJECTIVE

To study the precise location of fracture line in hangman's fracture to determine the fracture patterns, symmetry and involvement of different vertebral elements.

METHODS

32 cases of hangman's fractures were retrospectively evaluated. All patients presented with motor vehicle accidents. CT scans were studied to accurately localize the fracture lines. Symmetry of fracture lines on both sides was assessed, and involvement of the vertebral bodies, lamina, facet joints and foramen transversarium was also determined.

RESULTS

20 patients showed asymmetric fracture locations, 13 of them had a unilateral pedicle fracture and a contralateral pars fracture which comprised the most common injury pattern (40% of cases). Less frequent combinations for the two sides of asymmetric C2 ring disruption include pars-vertebral body (3 patients), pedicle-vertebral body (2 patients) and pedicle-lamina (2 patients). 12 patients showed symmetrical fractures (5 through the pars and 7 through the pedicles). Vertebral body and facet joint involvement were demonstrated in 15 (47%) and 16 (50%) cases, respectively. 18 cases had fractures extending into the foramen transversarium (56%). In total, 26 fracture lines primarily affected the pars (40%) and 31 affected the pedicles (49%).

CONCLUSION

Asymmetric hangman's fracture is more common with the usual pattern being fracture pedicle on one side and pars on the other followed by the symmetric bilateral pedicle and bilateral pars fractures. Fracture lines running into the transverse foramen and facet joints are very frequent as well as those involving the vertebral bodies.

ADVANCES IN KNOWLEDGE

There is controversy in literature regarding the fracture locations in hangman's injury owing to lack of studies that address this subject. This article is the first to describe precisely the anatomical locations and patterns of this injury.

Imaging Review of the Temporal Bone: Part II. Traumatic, Postoperative, and Noninflammatory Nonneoplastic Conditions

The first part of this review of the temporal bone discussed anatomy of the temporal bone as well as inflammatory and neoplastic processes in the temporal bone region (1). This second part will first discuss trauma to the temporal bone and posttraumatic complications. The indications for common surgical procedures performed in the temporal bone and their postoperative imaging appearance are then presented. Finally, a few noninflammatory nonneoplastic entities involving the temporal bone are reviewed. They are relatively uncommon diagnoses compared with infectious or inflammatory diseases. However, because patients present with symptoms that are either common (hearing loss) or distinctive (sensorineural hearing loss in a child), they are important for the radiologist to be aware of and recognize.

Predictors of Vertebral Artery Injury in Isolated C2 Fractures Based on Fracture Morphology Using CT Angiography

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To determine C2 fracture patterns associated with vertebral artery injury (VAI) as assessed by computed tomography angiography.

SUMMARY OF BACKGROUND DATA

The incidence of C2 fracture hospitalizations has increased significantly in the last decade. The vertebral arteries are susceptible to injury as each courses through the C2 transverse foramen. Early screening for VAI to institute antithrombotic treatment is critical to prevent ischemic neurological sequelae. Imaging-based fracture classification schemes to determine which patterns are predictors of VAI in isolated C2 fractures using computed tomography angiography have not been described.

METHODS

Cervical spine computed tomographic (CT) scans at a level I trauma center were reviewed for isolated C2 fractures from 2004 to 2014 under institutional board review approval. Exclusion criteria included penetrating injury or additional cervical/occipital fractures. Fractures were classified using multiplanar CT scans into type I/II/IIa/III spondylolisthesis, type I/IIA/IIB/IIC/III dens, transverse foramen (displacement/comminution/intraforaminal fragments), and miscellaneous vertebral body fractures. Corresponding CT angiograms were assessed for VAI on the basis of the Denver grading criteria. Fisher exact test and Student t test were performed to determine predictors of VAI on the basis of fracture type.

RESULTS

Sixty-seven patients met inclusion criteria. Fracture pattern analysis revealed that the majority were dens fractures (50.8%) and traumatic spondylolisthesis (41.8%); 29.9% had miscellaneous coronal/sagittal fractures and 22.4% were a combination.VAI was identified in 37.3% of patients with isolated C2 fractures, and 88% of patients had transverse foramen involvement. Fracture patterns significantly associated with VAI were type III dens and transverse foramen fractures with intraforaminal fragments, with or without comminution.

CONCLUSION

The C2 fracture pattern most associated with VAI was comminuted transverse foramen fracture with intraforaminal fragments. Transverse foramen fracture alone was not found to be significant. These results help stratify patients with isolated C2 fractures who are at high VAI risk and should be further evaluated with computed tomography angiography.

LEVEL OF EVIDENCE

3.

Imaging in Chronic Traumatic Encephalopathy and Traumatic Brain Injury

Context:

The diagnosis of chronic traumatic encephalopathy (CTE) can only be made pathologically, and there is no concordance of defined clinical criteria for premorbid diagnosis. The absence of established criteria and the insufficient imaging findings to detect this disease in a living athlete are of growing concern.

Evidence Acquisition:

The article is a review of the current literature on CTE. Databases searched include Medline, PubMed, JAMA evidence, and evidence-based medicine guidelines Cochrane Library, Hospital for Special Surgery, and Cornell Library databases.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

Chronic traumatic encephalopathy cannot be diagnosed on imaging. Examples of imaging findings in common types of head trauma are discussed.

Conclusion:

Further study is necessary to correlate the clinical and imaging findings of repetitive head injuries with the pathologic diagnosis of CTE.

Imaging evidence and recommendations for traumatic brain injury: advanced neuro- and neurovascular imaging techniques

SUMMARY

Neuroimaging plays a critical role in the evaluation of patients with traumatic brain injury, with NCCT as the first-line of imaging for patients with traumatic brain injury and MR imaging being recommended in specific settings. Advanced neuroimaging techniques, including MR imaging DTI, blood oxygen level-dependent fMRI, MR spectroscopy, perfusion imaging, PET/SPECT, and magnetoencephalography, are of particular interest in identifying further injury in patients with traumatic brain injury when conventional NCCT and MR imaging findings are normal, as well as for prognostication in patients with persistent symptoms. These advanced neuroimaging techniques are currently under investigation in an attempt to optimize them and substantiate their clinical relevance in individual patients. However, the data currently available confine their use to the research arena for group comparisons, and there remains insufficient evidence at the time of this writing to conclude that these advanced techniques can be used for routine clinical use at the individual patient level. TBI imaging is a rapidly evolving field, and a number of the recommendations presented will be updated in the future to reflect the advances in medical knowledge.

Intracranial pseudoaneurysm associated with orbitozygomatic complex fracture

Fractures of the orbitozygomatic complex are one of the most common facial fractures encountered by plastic surgeons. Many would consider this to be primarily a cosmetic deformity; however, these injuries can be associated with acute life-threatening complications. Intracranial pseudoaneurysm, although rare, is a well-documented complication of blunt facial trauma, which most plastic surgeons are unaware of. We present the case of a 20-year-old woman who developed an intracranial pseudoaneurysm after blunt facial trauma to illustrate the importance of (1) understanding this rare but highly morbid complication, (2) assessing high-risk patients for pseudoaneurysm, and (3) delaying reconstruction in high-risk patients.

Vertebral artery injury in destabilized midcervical spine trauma; predisposing factors and proposed mechanism

BACKGROUND

By now it has been well established that vertebral artery injury (VAI) is associated with unstable cervical spine injuries resulting from blunt trauma. A more complete understanding of predisposing factors and the mechanism of injury in VAI should result in improved outcomes and reduced risk for patients with VAI associated with unstable cervical spine injury following blunt trauma. The authors report statistical outcome and hypothesis to more thoroughly examine the predisposing factors for VAI, of which management is controversial, in destabilized midcervical spine trauma.

METHODS

Ninety-one of 131 consecutive patients who underwent surgery for a traumatically destabilized subaxial cervical spine were included, and results were analyzed statistically by logistic regression.

RESULTS

Eighteen patients (19.8 % of 91 patients) had a VAI associated with midcervical spine trauma (C2-C6). In univariate statistical analysis, transverse foramen fracture (P = 0.002), facet dislocation (P = 0.014), and facet fracture (P = 0.001) were significant risk factors. However, only facet fracture was determined to be significant risk factor after multivariate analysis (P = 0.006, odds ratio 20.98). It is hypothesized that a VAI occurs in a midcervical spine injury when a facet fracture allows the bony compartment to impinge on the relatively narrow free space of the intervertebral foramen, which is also occupied by the cervical root.

CONCLUSION

A facet fracture is the most important risk factor for VAI in patients with a destabilized midcervical spine injury. Patients with a C2-C6 facet fracture may require a definitive evaluation with vertebral artery imaging.

Imaging evaluation of adult spinal injuries: emphasis on multidetector CT in cervical spine trauma

As computed tomography (CT) technology has evolved, multidetector CT has become an integral part of the initial assessment of many injured patients, and the spine is easily included in the total body screening performed in patients with severe blunt polytrauma. Despite all the advantages of multidetector CT, clearing the spine in which injury is suspected continues to be a daily challenge in clinical practice. The purpose of this review is to present the evidence and the controversies surrounding the practice of imaging in patients suspected of having spine injury. The discussion is centered on the increasing reliance on multidetector CT in the work-up of these patients but also considers the important contributions of clinical trials to select patient for appropriate imaging on the basis of risk and probability of injury. Available protocols, injury classification systems, and issues awaiting future research are addressed.

A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries

BACKGROUND

Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI.

STUDY DESIGN

Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present.

RESULTS

The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI.

CONCLUSIONS

Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

The epidemiology of BCVI at a single state trauma centre

BACKGROUND

Blunt carotid and vertebral artery injury (BCVI) is a relatively uncommon but potentially devastating injury. The aim of our study was to highlight the incidence, patterns, presentation and associations of BCVI at our institution.

METHODS

Retrospective data between 1st January 2003 and 31st December 2006 was obtained from The Alfred Hospital's health information system, patient medical records and the Department of Neurosurgery's database. Injuries were graded using the Denver grading scale.

RESULTS

67 patients (0.64%) out of 10,417 minor and major trauma admissions, were diagnosed with BCVI. 33 (49%) sustained blunt carotid and 34 (51%) sustained blunt vertebral injuries. Motor vehicle accident (MVA) was the cause in 43 out of 67. 35% had associated head injury whilst 57% had concurrent cervical spine fractures. Odds ratio analysis showed that MVA victims with concomitant upper cervical spine injury were 22.9 times more likely to suffer BCVI than those without such risk factors. Approximately 50% of patients had a Glasgow coma score of 14 or less (GCS < or = 14). Grade 4 BCVI was most common. Stroke occurred in 22 (32%) and mortality in 14 (20%).

CONCLUSION

BCVI although infrequent, is a serious injury. Our study suggests that MVA patients with cervical spine fractures especially of the upper C-spine are at much higher risk of BCVI than those without such injuries.

Evaluation of the criteria for angiotomography indications in the diagnosis of carotid and vertebral arterial injury associated with blunt trauma

Background

Blunt carotid and vertebral artery injury (BCVI) occur infrequently. The incidence of this type of injury is difficult to determine as many emergency room patients are neurologically asymptomatic. The statistics have not been reported in Brazil. The objectives of the current study were: To evaluate the accuracy of criteria used to recommend angiotomography in the diagnosis of cervical BCVI in 100 patients with blunt cervical trauma in the trauma services section of a Brazilian quaternary care hospital.

Methods

During a 30-month (2006-2008), all patients admitted to the emergency room of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo with blunt cervical trauma and potential risk of cervical vessel injury, were subjected to cervical angiotomography to diagnose BCVI. The data analyzed are presented as mean ± standard deviation, and statistical analyses included Chi-square and Fisher's exact tests, and the Mann-Whitney test.

Results

During the study period 2467 blunt trauma patients were admitted. In 100 patients that met the criteria for inclusion in the study, angiotomography identified 23 with BCVI, including 17 males and six females. The mean patient age was 34.81 ± 14.84 years. Car crash (49%) and car-pedestrian accidents (24%) were the most frequent causes of injury. Ten patients had internal carotid artery injuries, two patients had common carotid artery injuries, and 11 patients had vertebral artery injuries. Seven patients presented with Degree I arterial injuries, 10 patients presented with Degree II artery injuries, four patients presented with Degree IV artery injuries, one patient presented with a Degree V artery injury, and one patient had a carotid fistula. Seven out of the 23 patients with BCVI (30.4%) presented with cervical vertebrae fractures, and 11 out of the 23 patients with BCVI (47.8%) presented with facial fractures (LeFort II and III).

Conclusions

Although there is no consensus regarding the criteria that should be used to indicate angiotomography for BCVI diagnosis, we conclude that the criteria used in the current study led to a diagnosis of BCVI in 0.93% of 2,467 trauma patients, BCVI injuries were associated with more severe traumas and did not affect mortality.

Correlation of C2 fractures and vertebral artery injury

STUDY DESIGN

Retrospective review of prospectively collected data.

SUMMARY OF BACKGROUND DATA

Vertebral artery injuries (VAI) occur commonly after cervical spine trauma. No study has yet examined the association between VAI and specific variants of C2 fractures.

OBJECTIVE

To evaluate the incidence of VAI (as defined by magnetic resonance imaging/angiography [MRI/A]) in subtypes of C2 fractures. To define the association between the incidence, morphology, and severity of C2 fractures, based on fracture angulation and comminution, and the occurrence of VAI.

METHODS

Patients admitted to the hospital with C2 fractures between October 2006 and December 2008 to a tertiary care referral center were identified through a prospectively maintained database. Computed tomography (CT) and MRI/A studies were individually reviewed to evaluate the specific C2 fracture type and the occurrence of VAI. Fracture displacement and angulation were measured. Incidence of VAI was compared between different types and subtypes of C2 fractures. The effects of displacement and angulation of the fracture, morphology of foramen transversarium fracture, patient age, and patient gender on VAI were also analyzed.

RESULTS

One hundred one patients were identified with C2 fractures that met inclusion criteria, and 18 (17.8%) had VAI by MRI/A. There was no correlation between fracture types and VAI. However, in subtype analysis, there was a correlation of VAI with traumatic spondylolisthesis of axis (TSA) and greater degree of angulation (P = 0.0023), communition fracture (P = 0.0341), and presence of bone fragment(s) within the foramen transversarium (P = 0.0075). Multivariate logistic regression indicated that age, gender and the presence of fragments within foramen transversarium were associated with greater risk of VAI.

CONCLUSION

Vertebral artery injuries are more likely to occur in C2 fractures with comminuted fractures involving the foramen transversarium, with fractures manifesting bony fragment(s) within the foramen transversarium, or with fractures having greater angulation. These risk factors should be considered when a patient presents with isolated axis fracture.

Does the morphology of foramen transversarium fractures predict vertebral artery injuries?

STUDY DESIGN

Retrospective review of foramen transversarium fracture morphology variables and their relationship to vertebral artery injury.

OBJECTIVE

We examined the morphology of foramen transversarium fractures to determine if different patterns of these fractures predicted vertebral artery injury to more specifically identify at risk patterns in which vertebral artery evaluation may be warranted.

SUMMARY OF BACKGROUND DATA

Risk fractures for vertebral artery injury have been previously reported to include cervical subluxation or dislocations, C1-C3 fractures, and foramen transversarium fractures. There have been no reports determining if specific foramen transversarium fracture patterns are predictive of vertebral artery injuries.

METHODS

We reviewed the initial cervical CT scans of 171 patients seen in our level one trauma center between January 2002 and March 2008 and identified all patients with foramen transversarium fractures. Additionally, CT angiograms were reviewed in these patients to identify patients with vertebral artery injuries. The morphology of the foramen transversarium fractures was compared in those patients with and without vertebral artery injury to identify fracture patterns predictive of arterial injury.

RESULTS

Twenty-one (12%) patients were found to have foramen transversarium fractures with 5 (24%) of these patients having associated vertebral artery injury. Multilevel foramen transversarium fractures (P = 0.025) were significantly more frequent in vertebral artery injuries. Logistic regression identified multilevel fractures (odds ratio 17.33) and fracture comminution (odds ratio 10.50) as significant variables influencing vertebral artery injury after foramen transversarium fracture.

CONCLUSION

We found patients presenting with multilevel foramen transversarium fractures and foramen transversarium fracture comminution to be at significantly increased odds of vertebral artery injury. Patients with these fracture patterns should undergo further evaluation with vertebral artery imaging.