A Lateral Mass Fracture of C1 Associated With Left Vertebral Artery and Mid-Basilar Artery Occlusion

Abstract

Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.

Basilar Artery Occlusion Following C1 Lateral Mass Fracture Managed by Mechanical and Pharmacological Thrombolysis

“…Our literature review suggested only two previous reports of C1 fracture and basilar artery occlusion where one patient suffered from locked-in syndrome while the other died [3,33]. In the case of our patient, it is likely that the C1 lateral mass fracture led to the vertebral artery dissection seen on angiography.…”

“…However, basilar artery occlusion in the setting of cervical spine trauma is rare and to our knowledge reported in only five cases [1][2][3][4][5]. Basilar artery occlusion is associated with high morbidity and mortality [6,7].…”

Locked-in syndrome caused by the pressure exerted by the sound gun

“…The frequency of improvement after posttraumatic damage is very rare, therefore difficult to diagnose. In the literature, there are isolated reports about the injuries caused by blunt[ 10 11 12 13 14 15 16 ] and penetrating[ 17 ] types of trauma, however in these cases vascular damage in the vertebrobasilar artery system and thrombotic occlusion are present. In the case report presented by Ahn and Aarabi,[ 18 ] there was no damage in the vertebrobasilar arterial system and it was indicated that LIS was caused by ventral pontomeduller contusion.…”

Traumatic, high-cervical, coronal-plane spondyloptosis with unilateral vertebral artery occlusion: treatment using a prophylactic arterial bypass graft, open reduction, and instrumented segmental fusion

“…39 This cautionary report highlights the importance of studying vascular anatomy closely in spondyloptosis, which can otherwise cause mobilization of a thrombus or propagation of dissection leading to catastrophic posterior circulation ischemia. 8,10,19,23,26,29,32,33,40 Vertebral artery injury is a rare but well recognized catastrophic iatrogenic complication of cervical spine surgery with a reported incidence of 0.3%-0.5%. 6,7,13,14,25,28,30 In the case presented in this report, the left VA was at risk during the exposure, osteotomies, and bone reduction for 2 reasons: 1) proximity of the artery to the partially autofused C2-3 vertebral bodies with potential for injury during osteotomy; and 2) anticipated significant alteration in its course that would occur with successful realignment, placing the vessel at risk for shear injury or kinking during translation.…”

“…Iatrogenic VA injury during cervical spine surgery has been documented to produce fistulas, late hemorrhages, pseudoaneurysm, thrombosis, and death. 8,10,19,23,26,29,32,33,40 Common techniques to reduce the risk of VA injury include the following: 1) partial excision of the longus colli muscle, allowing exposure of the uncinate processes and transverse processes; 2) careful uncectomy and removal of lateral osteophytes followed by uncovertebral joint resection up to the depth of the floor of the transverse foramen cephalad and caudal to the transverse process; 3) exposure large enough for proximal and distal control of the VA should inadvertent arterial injury be encountered while working on the fusion mass; and 4) use of neuronavigation and Doppler probe ultrasonography to more clearly identify the vessel near the fu sion mass.…”