Blunt cerebrovascular injuries in association with craniocervical distraction injuries: a retrospective review of consecutive cases

Marcelo D Vilela, Louis J Kim, Carlo Bellabarba, Richard J Bransford
Spine Journal: Official Journal of the North American Spine Society 2015 March 1, 15 (3): 499-505

BACKGROUND CONTEXT: Blunt cerebrovascular injuries (BCVIs) have the potential to cause brain, cerebellar, and/or spinal cord ischemia. Certain subtypes of spine fractures, such as vertebral subluxation, fractures through the foramen transversarium, and C1-C3 fractures have been linked to a higher incidence of BCVI. On the other hand, BCVI in association with craniocervical distraction injuries (CCDs) have been only anecdotally reported.

PURPOSE: We hypothesized that because CCD is also caused by a high-energy hyperflexion/hyperextension distraction mechanism, it could also be associated with a high incidence of BCVI.

STUDY DESIGN/SETTING: Retrospective chart review.

PATIENT SAMPLE: Of 46 consecutive patients with unstable craniocervical dissociations treated operatively at a single Level I trauma center from January 1996 to December 2009, 29 of the 46 had vascular studies that comprised the study sample.

OUTCOME MEASURES: Primary outcomes assessed were BCVI subdivided into blunt carotid artery injuries and/or blunt vertebral artery injuries and classified according to the Biffl criteria. Secondary measures included associated strokes and evidence of emboli on transcranial Doppler.

METHODS: All consecutive patients diagnosed with unstable CCD injuries that were surgically treated at a single Level I trauma center during the period of 1996 to 2009 were identified. Those who were adequately screened with a catheter angiogram and/or computed tomography angiogram of the neck so as to rule out BCVI were included in this study. Electronic medical records were used to determine mechanism, demographics, clinical findings, and transcranial Doppler reports. Angiography and computed tomography angiograms were analyzed to assess for BCVI. If a BCVI was identified, these were classified using the Biffl criteria.

RESULTS: Among the 29 screened patients, 30 BCVIs were identified in 15 patients. According to the Biffl criteria, there were 13 Grade I, eight Grade II, five Grade III, three Grade IV, and one Grade V injuries. Three major strokes were diagnosed in those 15 patients with BCVI, as opposed to none among the other 14 patients without BCVI.

CONCLUSIONS: Blunt cerebrovascular injuries were seen in more than 50% of the patients screened, with major strokes occurring in 20% of the patients. We suggest screening for BCVI in all patients presenting with C0-C1 and/or C1-C2 distraction injuries.

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