Bilateral cerebellar and brain stem infarction resulting from vertebral artery injury following cervical trauma without radiographic damage of the spinal column: A case report

Abstract

Vertebral artery injury can be a complication of cervical spine injury. Although most cases are asymptomatic, the rare case progresses to severe neurological impairment and fatal outcomes. We experienced a case of bilateral cerebellar and brain stem infarction with fatal outcome resulting from vertebral artery injury associated with cervical spine trauma. A 69-year-old male was admitted to our hospital because of tetraplegia after falling down the stairs and hitting his head on the floor. Marked bony damage of the cervical spine was not apparent on radiographs and CT scans, so the injury was initially considered to be a cervical cord injury without bony damage. However, an intensity change in the intervertebral disc at C5/C6, and a ventral epidural hematoma were observed on MRI. A CT angiogram of the neck showed the right vertebral artery was completely occluded at the C4 level of the spine. Forty-eight hours after injury, the patient lapsed into drowsy consciousness. The cranial CT scan showed a massive low-density area in the bilateral cerebellar hemispheres and brain stem. Anticoagulation was initiated after a diagnosis of the right vertebral artery injury, but the patient developed bilateral cerebellar and brain stem infarction. The patient's brain herniation progressed and the patient died 52 h after injury. We considered that not only anticoagulation but also treatment for thrombosis would have been needed to prevent cranial embolism. We fully realize that early and appropriate treatment are essential to improve the treatment results, and constructing a medical system with a team of orthopedists, radiologists, and neurosurgeons is also very important.

Cervical radiculopathy

“…The uncertain benefits provided by manipulation must be considered in the context of the potential for catastrophic complications that exists with cervical manipulation [6,[29][30][31][32][33]. While the exact rate of vertebral artery injury following manipulation is unknown, the odds ratio for vertebral artery dissection and vertobrobasilar artery stroke in young patients following cervical manipulation ranges from 3 to 12 [31].…”

Delayed Brain Infarction due to Bilateral Vertebral Artery Occlusion Which Occurred 5 Days after Cervical Trauma

“…VA injuries after blunt cervical trauma have previously been considered to be rare; however, advancements in imaging modalities have greatly increased the rate of VA injury diagnoses 4 , 14 , 23) . These diagnoses are difficult because the majority of patients do not present with neurological symptoms 13 , 16 , 24) .…”

“…Screening for VA injury is warranted for certain high-risk patients at the time of presentation due to the potentials for both acute and delayed development of neurological sequelae 12 , 15 , 17) . However, VA injury is not always accompanied by bone or spinal cord injury 14) . Neck manipulations by chiropractors and physiotherapists have also been reported to be associated with VA injury without cervical fracture 4 , 20) .…”

“…Vertebral artery (VA) injuries commonly accompany blunt cervical trauma 4 , 11 , 15 , 24) . Across articles, the reported incidences of VA injuries after cervical trauma range from 13% to 46% 2 , 4 , 12 , 14 , 15) , and bilateral VA injuries are estimated to occur at approximately 10% of the frequency of unilateral VA injuries 12) . However, bilateral VA injury was previously considered to be rare because of inadequate imaging modalities 4 , 6 , 14) , or the clinical silence of this condition 2 , 16 , 24) .…”

“…Across articles, the reported incidences of VA injuries after cervical trauma range from 13% to 46% 2 , 4 , 12 , 14 , 15) , and bilateral VA injuries are estimated to occur at approximately 10% of the frequency of unilateral VA injuries 12) . However, bilateral VA injury was previously considered to be rare because of inadequate imaging modalities 4 , 6 , 14) , or the clinical silence of this condition 2 , 16 , 24) . The prompt diagnosis of VA injury requires a high index of suspicion, because the majority of patients exhibit no neurological symptom 4 , 7 , 13 , 20 , 24) .…”