Lateral medullary syndrome after neck injury

Carotid artery pseudoaneurysm resulting from an injury to the neck by a fouled baseball

OBJECTIVE

Blunt carotid artery injury resulting in either dissection or pseudoaneurysm is a rare entity that can result in significant morbidity and mortality if undiagnosed. Although unavoidable in certain traumatic situations such as motor vehicle collisions, direct neck trauma in sports may be preventable with the use of proper protective equipment.

CLINICAL PRESENTATION

The following report documents a case of extracranial carotid artery dissection resulting from a foul ball striking the upper, lateral neck of an umpire. The patient had transient right upper extremity monoparesis. He later presented with right hemiparesis and aphasia that resolved over several hours. Imaging studies demonstrated a left carotid pseudoaneurysm with evidence of left hemispheric embolic infarcts.

INTERVENTION

Systemic intravenous anticoagulation with heparin followed by oral anticoagulation with warfarin for 6 months, subsequently followed by aspirin monotherapy.

CONCLUSION

The use of standard protective equipment did not adequately cover the patient's neck in the region of the cervical carotid artery. This case illustrates that modification in current catcher and umpire equipment could potentially avoid this rare but significant vascular injury.

A patient with Wallenberg’s syndrome induced by severe cough

A 45-year-old man developed severe cough with cervical pain. The patient was unable to hold an upright position. The origin of the right posterior inferior cerebellar artery was not enhanced by angiography. MRI showed a high signal intensity string-like structure of the right vertebral artery. In young patients, Wallenberg's syndrome related to mild head trauma has been reported. However, none of the previous studies related to vertebral arterial dissection was induced by severe cough. When cervical pain is present in young patients with severe cough, MRI should be performed to evaluate the possibility of vertebral arterial dissection.

Lateral medullary syndrome after prone position for general surgery

IMPLICATIONS

We describe postoperative lateral medullary syndrome with myoclonic spasm. Improper head rotation during positioning in the anesthetized patient might obstruct the flow of the vertebral artery at the neck and result in diminished perfusion of the associated regions in patients with a history of cervical spinal trauma.

Carotid and vertebral artery dissections

Dissections of the carotid and vertebral arteries are a common cause of stroke in young adults. The diagnosis may be missed because the typical signs and symptoms are often delayed in onset, or easily confused with other more commonly encountered entities. Dissections of the carotid and vertebral arteries may occur spontaneously or may accompany mild to severe trauma. They present with a variety of findings including headache, neck and face pain, Horner's syndrome, or stroke.

Dynamic elongation of the vertebral artery during an in vitro whiplash simulation

Clinical signs of whiplash are presently not well understood. Vertebral artery (VA) stretch during trauma is a possible pathomechanism that could explain some aspects of the whiplash symptom complex. This study quantified the VA elongation during whiplash simulation using an in vitro model. Seven fresh human cadaveric specimens (occiput to C7 or T1) were carefully dissected, preserving the osteoligamentous structures. The right VA was replaced with a thin nylon-coated flexible cable. This cable was fixed at one end to the occipital bone and at the other end to a specially designed VA transducer. Physiological motion of the occiput and physiological elongation of the VA were measured with a standard flexibility test. Next the specimen was mounted on a specially designed sled and subjected to 2.5, 4.5, 6.5, and 8.5 g (1 g = 9.81 m/s2) horizontal accelerations. Elongation of the VA was continuously recorded from the start of the trauma. The average (standard deviation) physiological VA elongation was 5.8 (1.6) mm in left lateral bending and 4.7 (1.8) mm in left axial rotation. Flexion and extension did not result in any appreciable elongation of the VA. The maximum VA elongation during the whiplash trauma significantly correlated with the horizontal acceleration of the sled (R2 = 0.7, P < 0.05). The VA exceeded its physiological range by 1.0 (2.1), 3.1 (2.6), 8.9 (1.6), and 9.0 (5.9) mm in the 2.5-, 4.5-, 6.5-, and 8.5-g trauma classes respectively.

Traumatic lesion of the extracranial vertebral artery--a note-worthy potentially lethal injury

The autopsy findings from routine neuropathological investigations of the cervical spine after any history of trauma emphasized the vulnerability of the extracranial vertebral arteries. In 21 cases with trauma to the head and neck, normal autopsy procedures did not succeed in revealing an obvious cause of death. Traumatic lesions of the spinal cord such as contusion or neurorrhexis were seen in 10 cases. In 15 cases we observed different degrees and stages of traumatic lesions of the extracranial vertebral arteries. Sudden death due to acute brain stem ischemia might be considered as an explanation in some of these cases. Six case reports with traumatic vertebral artery (VA) lesions after severe or minor extracranial trauma are presented. A review of the literature revealed that this vascular injury has only rarely been directly established by gross pathological examination. Possible consequences of blunt trauma to the head and neck include angiorrhexis, subintimal, intramural and perivascular hemorrhage leading to a partial narrowing of the injured vessel. These processes can be complicated by thrombosis. Unilateral VA obliteration may be an occult risk of acute brain stem ischemia when associated with contralateral reduction of the posterior circulation.

Perforating injury of the neck and vertebral artery trauma

A 10-year-old schoolboy presented with a penetrating wound to the neck after a children's slide accident. A CT scan and endoscopy showed a traumatic oesophageal-cutaneous fistula. Neurologically the child deteriorated over a period of 34 hours and finally succumbed to a respiratory arrest. Post-mortem findings showed a hypoplastic right vertebral artery. In the left suboccipital triangle a venous clot had blocked the dominant artery thus leading to cerebellar and brainstem infarction. This extraluminal compression leading to obstruction of an otherwise non traumatized vertebral artery is unique in the literature.

Vertebral artery occlusion associated with closed head injury: report of three cases

Vertebral artery occlusion associated with closed head injury is an uncommon clinical entity. Three cases are presented with discussion of the mechanisms of injury, pathology, diagnosis, possible treatment modalities and autopsy findings in the two fatalities. Angiography is essential for diagnosis and in fatal cases post-mortem examination of the entire length of the vertebral arteries should be routine.

Non-penetrating arterial trauma and cerebral infarction in the young

In a retrospective study of 60 patients under the age of 45 with ischaemic stroke the commonest likely predisposing factor was trauma, which applied to 13 (22%) patients. In 9 of these patients neck movement was the most likely factor that precipitated the stroke and was the factor identified in all the 3 who had damage to the vertebral artery. The other 4 patients had sustained direct trauma in the neck area, 2 as a result of attempted strangulation and 2 by carrying heavy loads on the shoulder. There may be a delay between the traumatic event and manifestation of the stroke, probably because the initial damage, which is most likely a small tear, is of no immediate consequence, and the stroke results after thrombus has formed over the tear and subsequently embolised.

Wallenberg's syndrome caused by direct brainstem injury

A unique case of a shotgun wound producing a lateral medullary syndrome is reported. Evidence indicating direct brainstem injury and not vascular injury is presented. The long-term complications of this type of injury are stressed.