Bilateral vertebral artery transection following blunt trauma

INTRODUCTION: Blunt vertebral artery injury (BVI) is a potentially catastrophic event associated with a variety of trauma mechanisms, particularly in the setting of cervical spine injury. Early detection and treatment of BVI and blunt carotid artery injury (BCI) – collectively termed blunt cerebrovascular injuries (BCVI) – is a known determinant of favorable outcomes, except in the case of complete transection injuries. The limited existing reports of these injuries demonstrate a 100% mortality rate regardless of the management approach taken, and further investigation is essential in better understanding the nature of the injury and improving patient outcomes. PRESENTATION OF CASE: A 55 year old previously healthy patient was brought to the Emergency Department following a motor vehicle collision. The patient was alert upon arrival to the ED and complained of neck pain. Initial assessment was significant for open fracture of the left upper extremity, swelling of the anterior neck, and no purposeful movements noted of the lower extremities. Shortly thereafter, the patient showed a sudden decline in mental status and became hemodynamically unstable. Focused Assessment with Sonography for Trauma was positive, and after remaining unstable despite resuscitation efforts, the patient was brought emergently to the operating room. DISCUSSION: Following exploratory laparotomy for bleeding control and washout of the open fracture, CT angiogram of the head and neck was obtained. This revealed significant C5–C6 dissociation as well as bilateral vertebral artery transection and large prevertebral hematoma. Prior to any further surgical intervention, the patient’s neurologic function continued to decline, and brain CT demonstrated infarcts in the posterior cerebral artery distribution. Brain death was confirmed the next day, and all care was subsequently withdrawn. CONCLUSIONS: Analysis of outcomes in patients with BCVI suggests that BVI should be distinguished from the better-studied CVI. Each injury type has been found to possess its own distinct risk factors, likelihoods of progression, and surgical accessibility, all of which affect management. Data on complete vessel transections remains limited for all BCVIs, with no documented cases of bilateral BVI to date. Our case study supports the 100% mortality rate seen in previously reported BCVI transections. Furthermore, our findings suggest that BVI transections occur in patients with coexisting injuries, which challenges the ability to attribute a single neurologic outcome to any one injury.