Presentation
Pedestrian struck by a car. Then head strike on the ground. At the scene was GCS 3 and intubated.
Patient Data
- Irregularity of the dominant right vertebral artery at the base of the C3 transverse foramen is suspicious for non-occlusive dissection.
- Subtle irregularity of the cavernous portion of the left internal carotid artery raises the possibility of an internal carotid dissection.
- The cervical and intracranial carotid arteries opacify normally elsewhere.
- The circle of Willis opacifies normally, with no evidence of branch occlusion.
Case Discussion
Traumatic vertebral artery dissection is a type of blunt cerebrovascular injury. It is clinically relevant due to the risk of posterior circulation ischemia1.
Motor vehicle accidents are the most common cause of traumatic vertebral injury2. Of these cases, unilateral traumatic vertebral artery injury is symptomatic in only up to 20% of cases. This is due to the significant collateral supply of the posterior circulation.
Symptoms are largely due to compromisation of the cerebellum, brainstem and visual cortex, which includes:
- headache, dizziness, nausea and vomiting, sensory and gait distrubance as well as speech and visual abnormalities.
CT angiography is used for diagnosis. This is because it has good sensitivity, fast examination time and a decreased rate of stroke compared to digital subtraction angiography.
Management for vertebral artery dissections include:
- Conservative management - observation
- Anticoagulation - can be given to asymptomatic patients who do not have any contraindications
- Endovascular intervention - stenting, occlusion, pseudoaneurysm coil embolization
- Open surgical management - rarely performed, but may be indicated in patients who cannot receive anticoagulation and have failed endovascular intervention
Case contributed by A/Prof. Pramit Phal.
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