Distal Embolic Brain Infarction Due to Recanalization of Asymptomatic Vertebral Artery Occlusion Resulting From Cervical Spine Injury: A Case Report

Abstract

Objective: The purpose of this case report is to describe a patient with brain infarction due to recanalization of an occluded vertebral artery (VA) following closed reduction and open fixation of cervical spinal dislocation and to discuss the management of asymptomatic VA injuries associated with spine trauma. Clinical Features: A 41-year-old Asian man experienced a C4-5 distractive-flexion injury manifesting with quadriplegia and anesthesia below the C3 cord level (including phrenic nerve paralysis), and bowel and bladder dysfunction. Magnetic resonance angiography and computed tomography angiography showed left extracranial VA (V2) occlusion and a patent contralateral VA. Intervention and Outcome: The patient was observed without antiplatelet and/or anticoagulation therapy and underwent open reduction and internal fusion of C4/5 and tracheostomy 8 hours after the injury. After surgery, supraspinal symptoms such as left horizontal nystagmus and left homonymous hemianopsia led to cranial computed tomography and magnetic resonance imaging, which showed left-side cerebellar infarction in the posterior inferior cerebellar artery territory and right-side posterior cerebral artery infarction. Magnetic resonance angiography and computed tomography angiography demonstrated patent bilateral VA (but hypoplastic right VA) and occluded right posterior cerebral artery. The injured VA was treated conservatively, and there were no other ischemic complications. Conclusion: The management of asymptomatic VA injury is controversial, with several treatment options available, including observation alone, antiplatelet therapy, anticoagulation therapy, or invasive intervention. Although there are some reports described where management with observation alone seems safe, serious attention should be given to the VA injury caused by cervical spine trauma.

Atlas Fracture with Concomitant Vertebral Artery Hypoplasia, a Rare but Potentially Hazardous Combination: A Case Report

“…For our patient, with VAH, the possibility of complications after cervical spine trauma seems to be higher [11]. It is well reported in the literature that a hypoplastic VA seems to be more susceptible to pro-thrombotic or atherosclerotic processes than normal VA and therefore a possible VA injury in a pre-existing contralateral hypoplastic VA could be extremely hazardous for brain ischemia, temporary or permanent neurological deficits and death [16]. Under no doubt, the early radiological investigation and diagnosis of this condition, allowed us to treat the patient in an appropriate way (with LMWH for three weeks and continued with anti-platelets) [15].…”

Awareness of traumatic occult lateral mass fracture of the cervical spine triggered by the presence of unilateral vertebral artery occlusion: a case report

“…No antithrombotic treatment was performed for the VA occlusion because of the potential risk for increased bleeding during surgery. There is controversy in the treatment of blunt VA occlusion between the use of embolization and antithrombotic therapy regarding the benefits gained by blood flow and the risk of developing a reperfusion disorder [10,25,26]. Furthermore, we previously experienced the occurrence of delayed secondary bilateral VA occlusion after inadequate management of traumatic cervical spine injury [20].…”

Delayed bilateral vertebral artery occlusion after cervical spine injury: a case report

“…2 Blood flow can be regained by quick and appropriate reduction and fusion; however, cerebral hemorrhage can secondarily occur because of thrombotic embolism and reperfusion disorder associated with blood reflow. 3 Although there are some institutions where embolization is performed for the vertebral artery to prevent these events, [4][5][6] the balance between benefits gained by blood reflow and the risk of developing reperfusion disorder is controversial. 7 At our hospital, we rarely perform embolization in advance for patients with vertebral artery occlusion; therefore, we have not experienced cases of thrombotic embolism or hemorrhagic infarction caused by reperfusion disorder.…”