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Extensive brain infarctions from bilateral vertebral artery injury because of cervical hyperextension injury: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Gomez‐Rojas O, Hafeez A, Gandhi N, Berghea R, Halalau A. Bilateral Vertebral Artery Dissection: A Case Report with Literature Review. Case Rep Med 2020; 2020:8180926. [PMID: 33101417 PMCID: PMC7568148 DOI: 10.1155/2020/8180926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/24/2020] [Accepted: 04/13/2020] [Indexed: 12/20/2022] Open
Abstract
Vertebral artery dissection (VAD) is a rare cause of ischemic stroke in young patients. The largely nonspecific symptoms and delayed presentation pose a serious diagnostic challenge. Medical management with either anticoagulation or antiplatelet therapy is recommended, but there are no reports of successful dual therapy. We report a case of spontaneous bilateral vertebral artery dissections (VADs) treated with both anticoagulation and antiplatelet therapy and a literature review on clinical presentation and the current medical and surgical management options. A 37-year-old healthy female presented to the emergency department with worsening neck pain and headache for two weeks despite over-the-counter medication, block therapy, yoga, and deep tissue neck massage. She denied any trauma but admitted to multiple roller coaster rides over the past few months. CT angiography was concerning for VADs, and MRI brain revealed multiple strokes in the left posterior inferior cerebellar artery (PICA) territory. Cerebral arteriography confirmed the diagnosis of VADs. The patient was initiated on warfarin, along with atorvastatin and aspirin. She was discharged home with no complications and followed up with neurology as an outpatient. MR angiography after three months revealed complete resolution of the dissection. The patient did not report any bleeding complications from dual therapy.
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Affiliation(s)
- Olga Gomez‐Rojas
- Office of Occupational Health, Alexander von Humboldt Peruvian German School, Lima, Peru
| | - Adam Hafeez
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Nikhil Gandhi
- Internal Medicine Department, Ascension Health, St.John Hospital, Detroit, MI, USA
| | - Ramona Berghea
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Alexandra Halalau
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Yu NR, Eberhardt RT, Menzoian JO, Urick CL, Raffetto JD. Vertebral artery dissection following intravascular catheter placement: a case report and review of the literature. Vasc Med 2016; 9:199-203. [PMID: 15675185 DOI: 10.1191/1358863x04vm565cr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Vertebral artery dissections (VAD) are known to occur as a result of mechanical manipulations of the cervical region, traumatic injury, iatrogenic injury and are also known to arise spontaneously. We report a case of vertebral artery dissection following vertebral artery cannulation during a central line placement and review the literature. The patient underwent intravascular catheter placement that subsequently demonstrated arterial blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery cannulation. The catheter was removed at the bedside with pressure, and a subsequent duplex ultrasound scan revealed a vertebral artery dissection. There were no neurological sequelae. The patient was successfully anticoagulated with warfarin but died from unrelated complications. This case report describes the rare iatrogenic event of VAD and reviews its etiology, diagnosis, complications, and management.
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Affiliation(s)
- Nicholas R Yu
- Vascular Surgery, Boston Medical Center, Boston VA Medical Center Boston, MA, USA
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Akan H, Atalay K, Belet Ü, Özmen Z, Gelmez S. Emergency Endovascular Treatment of a Penetrating Vertebral Artery Injury with Detachable Coils. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140090501800119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The surgical approach is difficult and time-consuming in cases of injury to the bony canal segment of the vertebral artery. Diagnosis and treatment should be performed urgently if the patient has active bleeding. We present a patient with a left vertebral artery injury in a stab wound to the neck in whom emergency endovascular treatment was performed with detachable coils because of ongoing gross bleeding.
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Affiliation(s)
- H. Akan
- Ondokuz Mayis University Faculty of Medicine, Radiology Department; Samsun, Turkey
| | - K. Atalay
- Ondokuz Mayis University Faculty of Medicine, Radiology Department; Samsun, Turkey
| | - Ü. Belet
- Ondokuz Mayis University Faculty of Medicine, Radiology Department; Samsun, Turkey
| | - Z. Özmen
- Ondokuz Mayis University Faculty of Medicine, Radiology Department; Samsun, Turkey
| | - S. Gelmez
- Ondokuz Mayis University Faculty of Medicine, Radiology Department; Samsun, Turkey
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Yoshihara H, VanderHeiden TF, Harasaki Y, Beauchamp KM, Stahel PF. Fatal outcome after brain stem infarction related to bilateral vertebral artery occlusion - case report of a detrimental complication of cervical spine trauma. Patient Saf Surg 2011; 5:18. [PMID: 21756312 PMCID: PMC3161841 DOI: 10.1186/1754-9493-5-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Accepted: 07/14/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vertebral 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 PRESENTATION A 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. CONCLUSION Brain 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.
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Affiliation(s)
- Hiroyuki Yoshihara
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Todd F VanderHeiden
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Yasuaki Harasaki
- Department of Neurosurgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Kathryn M Beauchamp
- Department of Neurosurgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | - Philip F Stahel
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
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Yokota H, Atsumi T, Araki T, Fuse A, Sato H, Kawai M, Yamamoto Y. Significance of magnetic resonance imaging in the diagnosis of vertebral artery injury associated with blunt cervical spine trauma. J NIPPON MED SCH 2007; 74:293-9. [PMID: 17878699 DOI: 10.1272/jnms.74.293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Vertebral artery injury associated with non-penetrating cervical trauma is rare. We report 11 cases of vertebral artery injury diagnosed with magnetic resonance imaging (MRI) after blunt trauma to the cervical spine and discuss about the importance of MRI in the diagnosis of this injury. Seven cases were caused by motor vehicle accidents, three by diving accidents, and one by static compression of the neck. All of the patients had documented cervical spine fractures and dislocations. In three patients, the diagnosis of complete occlusion of the vertebral artery was made on the basis of MRI and digital subtraction angiography (DSA). In the other patients, mural injuries of the vertebral artery were demonstrated with DSA. These 11 patients presented with acute, nonspecific changes in neurological status. Two had infarctions of the cerebellum and brainstem. None were treated with anticoagulants. All of them survived and were discharged to other hospitals for physical and occupational therapy. Although DSA remains the gold standard for diagnosing vertebral artery injuries, MRI is a newer modality for assessing cervical cord injury, and it may be useful for evaluating the presence of vertebral injury after blunt cervical spine trauma.
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Affiliation(s)
- Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School Hospital, Tokyo, Japan.
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Nagurney JT, Feldman D, Cahill DP, Gatha NM, Koroshetz WJ. Unusual visual symptoms in a patient with bilateral vertebral artery dissection: A case report. J Emerg Med 2006; 31:169-71. [PMID: 17044579 DOI: 10.1016/j.jemermed.2005.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We present a previously unreported set of symptoms in a patient found to have bilateral vertebral dissections. Although visual symptoms are common in vertebral dissection, their pattern does not typically mimic those that commonly precede or accompany migraine headache. When they do occur, they usually take the form of diplopia or blurred vision. The patient we describe had visual symptoms that varied over three episodes of headache and included transient visual field loss and scintillations ("lightning bolts"), both common in migraine. However, our patient's new visual symptoms represented a change in pattern from those that had accompanied her previous migraines. This detailed history-taking prompted an evaluation for an etiology other than migraine and prevented a further delay in diagnosis and treatment.
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Affiliation(s)
- John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, 02115, USA
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Inamasu J, Guiot BH. Vertebral artery injury after blunt cervical trauma: an update. ACTA ACUST UNITED AC 2006; 65:238-45; discussion 245-6. [PMID: 16488240 DOI: 10.1016/j.surneu.2005.06.043] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Accepted: 06/15/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vertebral artery injury (VAI) after blunt cervical trauma has been considered to be rare. The incidence of VAI has increased dramatically within the last decade after a heightened awareness of this entity on the part of spine surgeons. Diagnostic or therapeutic guidelines for VAI have not been established fully, however. METHODS A review of the literature published between 1990 and 2004 was conducted. RESULTS The incidence of VAI among total blunt trauma admissions ranged from 0.20% to 0.77%. Most VAI patients remained asymptomatic, but sudden unexpected deterioration was often reported. Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. Digital subtraction angiography was the most sensitive imaging study, but because of invasiveness, its role as a screening study remained questionable. Neuroradiological intervention was used successfully to treat hemorrhagic VAI and progressing vertebrobasilar stroke. Systemic anticoagulation with heparin was the preferred treatment for mild ischemia. Treatment of asymptomatic patients has been controversial because the natural history of VAI has not been elucidated. Prophylactic anticoagulation with heparin or the use of antiplatelet agents was advocated in recent studies. CONCLUSIONS Preemptive treatment may be reasonable in selected patients considering the devastating potentials of VAI. The potential risks of heparin or antiplatelet agents in relation to early cervical spine surgery have not been addressed fully, however, and spine surgeons have to weigh the risk and benefit of such treatment cautiously.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, University of South Florida College of Medicine, Tampa, FL 33606, USA.
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Yong RL, Heran NS. Traumatic carotid cavernous fistula with bilateral carotid artery and vertebral artery dissections. Acta Neurochir (Wien) 2005; 147:1109-13; discussion 1113. [PMID: 16133778 DOI: 10.1007/s00701-005-0604-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Carotid and vertebral artery dissections from blunt cervical trauma are uncommon injuries that in recent years are becoming increasingly recognized as a result of angiographic screening protocols in trauma patients. Traumatic carotid cavernous fistulas are even less common events, but represent the most common intracranial vascular anomaly after head injury. The present report details the unique case of a woman with no history of collagen vascular disease who developed dissections of both carotid and both vertebral arteries, as well as a direct carotid cavernous fistula, after a motor vehicle collision. Her vascular injuries resolved without need for surgical or endovascular intervention.
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Affiliation(s)
- R L Yong
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada.
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Medhkour A, Chan M. An unusually favorable outcome of bilateral vertebral arterial dissections: case report and review of the literature. ACTA ACUST UNITED AC 2005; 58:1285-9. [PMID: 15995485 DOI: 10.1097/01.ta.0000171370.92018.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Azedine Medhkour
- Division of Neurological Surgery, The Medical College of Ohio, Toledo, Ohio 43614-5807, USA.
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Mwipatayi BP, Jeffery P, Beningfield SJ, Motale P, Tunnicliffe J, Navsaria PH. Management of extra-cranial vertebral artery injuries. Eur J Vasc Endovasc Surg 2004; 27:157-62. [PMID: 14718897 DOI: 10.1016/j.ejvs.2003.11.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To review the management of vertebral artery injuries, and the impact of pre-operative angiography. MATERIALS AND METHODS A retrospective review was conducted of all patients with vertebral artery (VA) injuries admitted to Groote Schuur Hospital, Cape Town between January 1987 and December 2002. Patients presenting with uncontrolled active bleeding or haemodynamic instability with a poor response to resuscitation were taken immediately to surgery. Stable patients, including those who stabilised after simple resuscitation, with evidence of a vascular injury (a bruit or a large haematoma) or trans-cervical gunshot wounds, underwent routine aortic arch and selective angiography. RESULTS One hundred and one patients with vertebral artery injuries were included in the study. Ninety-two patients sustained penetrating injuries (41 gunshot, 51 stab), three were iatrogenic and six due to blunt trauma. Angiography was performed as the primary investigation in 88 patients, while seven patients had angiography following surgery. Thirty-nine vertebral artery occlusions, 11 arteriovenous fistulae, two intimal injuries and 36 false aneurysms were identified. Thirty-three radiological interventions were performed. There were 22 associated vascular injuries in 16 patients, 27 nerve injuries in 25 patients, 11 osseous injuries in nine patients and eight aerodigestive injuries. Seven patients died. CONCLUSIONS Angiography and intervention is of great benefit in the diagnosis and management of traumatic vertebral artery injuries. Angiography often avoids unnecessary exploration and permits endovascular treatment.
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Affiliation(s)
- B P Mwipatayi
- Department of Surgery, Vascular Unit, Groote Schur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
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Pérez Navero JL, Montero-Shiemann C, Velasco Jabalquinto MJ, Ibarra de la Rosa I, Antón Gamero M, Salas Molina J. [Fatal outcome after severe cerebellar infarction due to spontaneous dissection of the vertebral artery]. An Pediatr (Barc) 2003; 58:385-9. [PMID: 12681189 DOI: 10.1016/s1695-4033(03)78074-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Cerebellar infarction due to vertebrobasilar ischemia in spontaneous vertebrobasilar dissection is infrequent in children and adolescents. The commonest pathogenic mechanism of cerebellar infarction is arterial occlusion. Although usually favorable, outcome can be fatal, as in the present case. A previously healthy 4-year-old girl was admitted to the emergency room with sensory failure and trembling. The previous week she had suffered from a transitory ischemic attack that resolved spontaneously. On admission to the emergency department, the Glasgow Coma Scale score was 10/15 and she presented irregular polypneic breathing, anisocoric reactive pupils, enhanced reflexes, lower limb clonus and bilateral pyramidal signs. Cranial computed tomography revealed marked hypodensity in both cerebellar hemispheres and white supratentorial substance with obliteration of the quadrigeminus cisterns. Cerebral angiography showed left vertebral artery dissection with distal pseudoaneurysm and marked basilar occlusion. Despite aggressive antiedemic treatment and early instauration of intravenous continuous sodium heparin infusion, the patient developed a bilateral cerebellar infarction and supratentorial hydrocephalus. Brain death was diagnosed after 48 hours. Postmortem pathologic examination revealed previous thrombus the in superior left cerebellar artery and basilar artery occlusion. We discuss the absence of predisposing factors and the transitory ischemic attack in this patient 1 week before she developed massive cerebellar infarction.
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Affiliation(s)
- J L Pérez Navero
- Unidad de Cuidados Intensivos Pediátricos, Servicio de Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofia. Cordoba. Spain.
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