Trauma Patient With Neurological Symptoms

John R. Gaughen, Jr., M.D.

August 15, 2005


This case demonstrates traumatic cervical vertebral artery dissection and occlusion caused by a fracture through the transverse foramen of the cervical spine. Etiologies for vertebral artery dissection are varied, including blunt or penetrating trauma, systemic disease (fibromuscular dysplasia or elastic tissue diseases), or spontaneous. The literature reports cases of dissection following seemingly trivial trauma, including roller coasters, chiropractic manipulation, and even sneezing and coughing. Clinical manifestations of vertebral artery dissection vary and can lead to difficulties and delay in diagnosis. Patients may be asymptomatic, or they may report neck pain, headache, and/or symptoms referable to the posterior circulation. Symptoms can manifest days or weeks or months after the initial dissection. CT is usually the first test performed in evaluating patients with vertebral artery occlusion or dissection, evaluating for complications, such as infarction or hemorrhage. CTA is sensitive for detecting dissections, with findings mirroring those of MRA. MRI/MRA is the most sensitive noninvasive test for evaluation of vertebral artery dissection or occlusion. On T1-weighted images, this appears as higher intensity replacing the normal flow-void of the vertebral artery. As seen in the case above, identification of vertebral artery dissection or occlusion can be difficult on T2-weighted images, secondary to high intensity blood in the vessel wall mimicking the high intensity normally seen within the vessel lumen. MRA clearly identifies dissections. The most common finding on MRA is irregular luminal narrowing or occlusion, with an intimal flap rarely seen. Because of the excellent sensitivity of MRI/MRA, it has largely replaced catheter angiography in the initial evaluation for detection of vertebral artery dissection. However, catheter angiography remains the gold standard for diagnosis of vertebral artery dissection. The classic finding associated with dissection is the "string of pearls" appearance of an irregularly narrowed lumen. Again, a dissection flap is rarely seen. While invasive, catheter angiography offers both diagnostic and potentially therapeutic benefit. Vertebral artery dissections often heal spontaneously. Likewise, traumatic cervical vertebral artery occlusions are often asymptomatic. Therefore, treatment often involves conservative management, with anticoagulation given to prevent distal embolization. Patients with more severe symptoms can be treated with endovascular or surgical approaches. Involvement of the basilar artery usually leads to devastating sequelae and carries a high mortality rate.

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