Traumatic vertebral arterial dissection in setting of multitrauma

Case contributed by Dr Heather Pascoe

Presentation

Pedestrian in MVA.

Patient Data

Age: 30
Gender: Male
CT

Brain and Cervical spine

Brain

  • Subtle thin (2mm) subdural hematoma in the right middle cranial fossa anterior to the right temporal lobe.
  • Right frontal bone fracture extending through the coronal suture into the right lateral orbital wall, across the orbital roof into the right medial orbital wall with extension into the ethmoid air cells and locules of gas in the extraconal space. The fracture line runs through the right greater and the lesser wing of the sphenoid bone, the right anterior clinoid process, the planum sphenoidale, the lateral wall of the right sphenoid sinus and into the lateral wall of the right optic canal, the medial wall of the sphenoid sinuses, the posterior wall of the left sphenoid sinus and the left anterior edge of the sellar turcica. Blood within the paranasal sinuses.
  • Minimally displaced nasal bone and bony nasal septum fractures.

C-spine

  • ETT and NGT
  • Undisplaced Type III odontoid fracture, extending into the left articular pillar.
  • Minimally displaced fracture through the right C5 foramen transversarium.
  • Comminuted fracture through the left C6 lamina extending into the superior articular facet, articular pillar and foramen transversarium and bilateral subluxed C5/6 facet joints.
  • Widened C5/6 disc space.
  • Right neck subcutaneous emphysema.
CT

CTA COW was performed. Reformat of the left vertebral artery.

Tapered left vertebral artery with no flow from C7 to C4 in keeping with vertebral artery dissection. This is consistent with the left C6 foramen transversarium fracture.

CT

Chest, Abdomen and Pelvis

Chest

  • ETT in the right main bronchus. NGT.
  • Right tension pneumothorax and subcutaneous emphysema overlying the right lateral chest wall.
  • Small anterior left sided pneumothorax with a left sided intercostal catheter.
  • Bilateral pulmonary contusions and collapse.
  • Multiple right sided rib fractures including a displaced lateral 8th rib fracture and undisplaced 2nd, 3rd and 10th rib fractures.
  • Old left posterior 6th and 7th rib fractures.
  • Manubrium step artefact mimicking a fracture (see skin step).
  • Comminuted midshaft right clavicle fracture.

Abdomen/Pelvis

  • Moderate stranding in the anterior pararenal space particularly on the left likely secondary to left adrenal trauma.
  • Small foci of hyperdense material layering in loops of the small bowel likely reflects ingested material rather than multiple sites of luminal active bleeding.
  • Hematoma in the subcutaneous tissues of the left anterior abdominal wall and the right hip.

Case Discussion

Fractures involving the foramen transversarium put the vertebral artery at risk of dissection or occlusion (and hence the possibility of stroke) and CTA is indicated when such a fracture is detected. 

Fractures of the odontoid are classified into 3 types. Type III fractures, as seen in this case, are the most likely type to heal without fixation due to the larger surface area.

A tension pneumothorax is a surgical emergency. Once a pneumothorax is identified, the next step is to evaluate if it is under tension. Signs suggestive of a tension pneumothorax include: mediastinal shift to the contralateral side; flattening or inversion of the ipsilateral hemidiaphragm and a hyperexpanded ipsilateral chest.

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Case information

rID: 32902
Published: 12th Jul 2015
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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