Hangman fracture (Levine and Edwards grade 2) and vertebral artery traumatic pseudoaneurysm (Biffl grade 3)

Case contributed by Craig Hacking


High speed MVA. Intubated at the scene.

Patient Data

Age: 20 years
Gender: Male

Bilateral C2 laminar fractures involving the right transverse foramen and right posterolateral aspect of the dens. 8 mm of fracture fragment separation at the right side. Associated grade 1 anterolisthesis of C2 on C3. Widening of the C1/C2 interspinous distance.

Endotracheal tube within the distal carina. Nasogastric tube in situ. Secretions diffusely within the paranasal sinuses, nasal cavity, and above the endotracheal tube cuff.


C2 Hangman fracture.

Co-dominant vertebral arteries. The right vertebral artery is displaced posteriorly from the right C2 vertebral foramina and is compressed between the C2 fracture fragments. A small outpouching of contrast is anterior to the artery at this level in keeping with a traumatic pseudoaneurysm. No dissection flap identified. Normal distal opacification.

Normal opacification of the intracranial arteries. No evolving cerebellar or occipital hypoattenuation.

Right mandibular fractures (assessed on separate facial bone recons).


Displacement and compression of the right vertebral artery by the C2 fracture fragments with small associated anterior traumatic pseudoaneurysm. BCVI Biffl grade 3.

Case Discussion

This case is a good example of a Biffl grade 3 injury to the vertebral artery.

The Biffl grade for blunt cerebrovascular injury (BCVI) describes a 5-part scale of injury features:

  • grade I:  mild intimal injury or irregular intima
  • grade II: dissection with raised intimal flap / intramural hematoma with luminal narrowing >25% / intraluminal thrombosis
  • grade IIIpseudoaneurysm
  • grade IV: vessel occlusion/thrombosis
  • grade V: vessel transection

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