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

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Abstract

Background

Vertebral artery injury following cervical spine trauma can be associated with stroke. We present a case of a C1 fracture resulting in vertebral artery dissection and neurological decline as a result of basilar artery occlusion treated with chemical and mechanical thrombolysis resulting in basilar artery patency and clinical improvement.

Case description

The patient is a 43-year-old female who was involved in a motor vehicle collision where she sustained multiple cervical spine injuries including a comminuted fracture of the left lateral mass of C1 resulting in vertebral artery dissection which eventually led to a basilar artery embolus and occlusion. A total of 15 mg of intraarterial tissue plasminogen activator was infused throughout the clot, followed by mechanical clot embolectomy using an FDA-approved device. Her neurological exam improved post-procedurally and she was discharged with a left hemiparesis to a rehabilitation facility 3 weeks after admission. At 15 month follow up, she is neurologically intact with the exception of some subtle difficulty with fine motor movement in the right upper extremity and mild dysmetria on the right.

Conclusions

With this case, we report a rare and potentially devastating complication of C1 fracture. To our knowledge there are only two previously reported cases where a C1 fracture has been associated with basilar artery occlusion resulting in death and locked-in syndrome respectively. In this case, chemical thrombolysis and mechanical thrombectomy resulted in recanalization of the basilar artery with excellent long-term neurological outcome.

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References

  1. Debehnke DJ, Singer JI. Vertebrobasilar occlusion following minor trauma in an 8-year-old boy. Am J Emerg Med. 1991;9(1):49–51. doi:10.1016/0735-6757(91)90015-C.

    Article  PubMed  CAS  Google Scholar 

  2. Fitzgerald LF, Simpson RK, Trask T. Locked-in syndrome resulting from cervical spine gunshot wound. J Trauma. 1997;42(1):147–9. doi:10.1097/00005373-199701000-00028.

    Article  PubMed  CAS  Google Scholar 

  3. Schoeggl A, Reddy M, Bavinzski G. A lateral mass fracture of C1 associated with left vertebral artery and mid-basilar artery occlusion. J Neurotrauma. 2001;18(7):737–41. doi:10.1089/089771501750357672.

    Article  PubMed  CAS  Google Scholar 

  4. Shibata T, Ogiichi T, Miyake T, et al. A case of basilar artery occlusion of traumatic vertebral artery dissection successfully managed by endovascular treatment. No Shinkei Geka. 2003;31(3):311–6.

    PubMed  Google Scholar 

  5. Woolsey RM, Chung HD. Fatal basilar artery occlusion following cervical spine injury. Paraplegia. 1979;17(3):280–3.

    PubMed  CAS  Google Scholar 

  6. Baird TA, Muir KW, Bone I. Basilar artery occlusion. Neurocrit Care. 2004;1(3):319–29. doi:10.1385/NCC:1:3:319.

    Article  PubMed  Google Scholar 

  7. Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ. Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988;19(10):1216–22.

    PubMed  CAS  Google Scholar 

  8. Gonzalez A, Mayol A, Martinez E, Gonzalez-Marcos JR, Gil-Peralta A. Mechanical thrombectomy with snare in patients with acute ischemic stroke. Neuroradiology. 2007;49(4):365–72. doi:10.1007/s00234-006-0207-8.

    Article  PubMed  Google Scholar 

  9. Lin DDM, Gailloud P, Beauchamp NJ, Aldrich EM, Wityk RJ, Murphy KJ. Combined stent placement and thrombolysis in acute vertebrobasilar ischemic stroke. AJNR Am J Neuroradiol. 2003;24(9):1827–33.

    PubMed  Google Scholar 

  10. Price RF, Sellar R, Leung C, O’Sullivan MJ. Traumatic vertebral arterial dissection and vertebrobasilar arterial thrombosis successfully treated with endovascular thrombolysis and stenting. AJNR Am J Neuroradiol. 1998;19(9):1677–80.

    PubMed  CAS  Google Scholar 

  11. Smith WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol. 2006;27(6):1177–82.

    PubMed  CAS  Google Scholar 

  12. Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36(7):1432–8. doi:10.1161/01.STR.0000171066.25248.1d.

    Article  PubMed  Google Scholar 

  13. Taneichi H, Suda K, Kajino T, Kaneda K. Traumatically induced vertebral artery occlusion associated with cervical spine injuries: prospective study using magnetic resonance angiography. Spine. 2005;30(17):1955–62. doi:10.1097/01.brs.0000176186.64276.d4.

    Article  PubMed  Google Scholar 

  14. Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg. 2000;231(5):672–81. doi:10.1097/00000658-200005000-00007.

    Article  PubMed  CAS  Google Scholar 

  15. Friedman D, Flanders A, Thomas C, Millar W. Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences. AJR Am J Roentgenol. 1995;164(2):443–7; discussion 8–9.

    PubMed  CAS  Google Scholar 

  16. Giacobetti FB, Vaccaro AR, Bos-Giacobetti MA, et al. Vertebral artery occlusion associated with cervical spine trauma. A prospective analysis. Spine. 1997;22(2):188–92. doi:10.1097/00007632-199701150-00011.

    Article  PubMed  CAS  Google Scholar 

  17. Louw JA, Mafoyane NA, Small B, Neser CP. Occlusion of the vertebral artery in cervical spine dislocations. J Bone Joint Surg Br. 1990;72(4):679–81.

    PubMed  CAS  Google Scholar 

  18. Weller SJ, Rossitch E Jr, Malek AM. Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography. J Trauma. 1999;46(4):660–6. doi:10.1097/00005373-199904000-00017.

    Article  PubMed  CAS  Google Scholar 

  19. Willis BK, Greiner F, Orrison WW, Benzel EC. The incidence of vertebral artery injury after midcervical spine fracture or subluxation. Neurosurgery. 1994;34(3):435–41; discussion 41–2. doi:10.1097/00006123-199403000-00008.

    Article  PubMed  CAS  Google Scholar 

  20. Deen HG Jr, McGirr SJ. Vertebral artery injury associated with cervical spine fracture. Report of two cases. Spine. 1992;17(2):230–4. doi:10.1097/00007632-199202000-00019.

    Article  PubMed  Google Scholar 

  21. Vaccaro AR, Klein GR, Flanders AE, Albert TJ, Balderston RA, Cotler JM. Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography. Spine. 1998;23(7):789–94; discussion 95. doi:10.1097/00007632-199804010-00009.

    Article  PubMed  CAS  Google Scholar 

  22. Veras LM, Pedraza-Gutierrez S, Castellanos J, Capellades J, Casamitjana J, Rovira-Canellas A. Vertebral artery occlusion after acute cervical spine trauma. Spine. 2000;25(9):1171–7. doi:10.1097/00007632-200005010-00019.

    Article  PubMed  CAS  Google Scholar 

  23. Cothren CC, Moore EE, Ray CE Jr, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. Surgery. 2007;141(1):76–82. doi:10.1016/j.surg.2006.04.005.

    Article  PubMed  Google Scholar 

  24. Cornacchia LG, Abitbol JJ, Heller J, Schneiderman G, Garfin S, Marshall LF. Blunt injuries to the extracranial cerebral vessels associated with spine fractures. Spine. 1991;16(10):S506–10. doi:10.1097/00007632-199110001-00010.

    Article  PubMed  CAS  Google Scholar 

  25. Lyness SS, Simeone FA. Vascular complications of upper cervical spine injuries. Orthop Clin North Am. 1978;9(4):1029–38.

    PubMed  CAS  Google Scholar 

  26. Smith WS. Intra-arterial thrombolytic therapy for acute basilar occlusion: pro. Stroke. 2007;38(2):701–3. doi:10.1161/01.STR.0000247897.33267.42.

    Article  PubMed  Google Scholar 

  27. Kubik CS, Adams RD. Occlusion of the basilar artery—a clinical and pathological study. Brain. 1946;69(2):73–121. doi:10.1093/brain/69.2.73.

    Article  Google Scholar 

  28. Ferbert A, Bruckmann H, Drummen R. Clinical features of proven basilar artery occlusion. Stroke. 1990;21(8):1135–42.

    PubMed  CAS  Google Scholar 

  29. Smith E, Delargy M. Locked-in syndrome. BMJ. 2005;330(7488):406–9. doi:10.1136/bmj.330.7488.406.

    Article  PubMed  Google Scholar 

  30. Voetsch B, DeWitt LD, Pessin MS, Caplan LR. Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2004;61(4):496–504. doi:10.1001/archneur.61.4.496.

    Article  PubMed  Google Scholar 

  31. Schonewille WJ, Algra A, Serena J, Molina CA, Kappelle LJ. Outcome in patients with basilar artery occlusion treated conventionally. J Neurol Neurosurg Psychiatry. 2005;76(9):1238–41. doi:10.1136/jnnp.2004.049924.

    Article  PubMed  CAS  Google Scholar 

  32. Walker ID. Exogenous sex hormones and thrombophilia. Obstet Gynecol Clin North Am. 2006;33(3):467–79, x. doi:10.1016/j.ogc.2006.05.008.

    Article  PubMed  Google Scholar 

  33. Schwarz N, Buchinger W, Gaudernak T, Russe F, Zechner W. Injuries to the cervical spine causing vertebral artery trauma: case reports. J Trauma. 1991;31(1):127–33. doi:10.1097/00005373-199101000-00025.

    Article  PubMed  CAS  Google Scholar 

  34. Kontautas E, Ambrozaitis KV, Kalesinskas RJ, Spakauskas B. Management of acute traumatic atlas fractures. J Spinal Disord Tech. 2005;18(5):402–5. doi:10.1097/01.bsd.0000177959.49721.3b.

    Article  PubMed  Google Scholar 

  35. Mangiafico S, Cellerini M, Nencini P, Gensini G, Inzitari D. Intravenous tirofiban with intra-arterial urokinase and mechanical thrombolysis in stroke: preliminary experience in 11 cases. Stroke. 2005;36(10):2154–8. doi:10.1161/01.STR.0000181751.06736.64.

    Article  PubMed  CAS  Google Scholar 

  36. Mayer TE, Hamann GF, Brueckmann HJ. Treatment of basilar artery embolism with a mechanical extraction device: necessity of flow reversal. Stroke. 2002;33(9):2232–5. doi:10.1161/01.STR.0000024524.71680.C6.

    Article  PubMed  Google Scholar 

  37. Yu W, Binder D, Foster-Barber A, Malek R, Smith WS, Higashida RT. Endovascular embolectomy of acute basilar artery occlusion. Neurology. 2003;61(10):1421–3.

    PubMed  CAS  Google Scholar 

  38. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999;282(21):2003–11. doi:10.1001/jama.282.21.2003.

    Article  PubMed  CAS  Google Scholar 

  39. Egan R, Clark W, Lutsep H, Nesbit G, Barnwell S, Kellogg J. Efficacy of intraarterial thrombolysis of basilar artery stroke. J Stroke Cerebrovasc Dis. 1999;8(1):22–7. doi:10.1016/S1052-3057(99)80035-4.

    Article  PubMed  CAS  Google Scholar 

  40. Arnold M, Nedeltchev K, Schroth G, et al. Clinical and radiological predictors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis. J Neurol Neurosurg Psychiatry. 2004;75(6):857–62. doi:10.1136/jnnp.2003.020479.

    Article  PubMed  CAS  Google Scholar 

  41. Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39(4):1205–12. doi:10.1161/STROKEAHA.107.497115.

    Article  PubMed  Google Scholar 

  42. Flint AC, Duckwiler GR, Budzik RF, Liebeskind DS, Smith WS. Mechanical thrombectomy of intracranial internal carotid occlusion: pooled results of the MERCI and Multi MERCI Part I trials. Stroke. 2007;38(4):1274–80. doi:10.1161/01.STR.0000260187.33864.a7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair, Suite 2210, Chicago, IL, 60611, USA

    Patrick A. Sugrue, Ziad A. Hage, Daniel L. Surdell, John Liu & Bernard R. Bendok

  2. Department of Neurosurgery, Northwest Community Hospital, Arlington Heights, IL, USA

    Mina Foroohar

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  1. Patrick A. Sugrue
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  2. Ziad A. Hage
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Correspondence to Bernard R. Bendok.

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Sugrue, P.A., Hage, Z.A., Surdell, D.L. et al. Basilar Artery Occlusion Following C1 Lateral Mass Fracture Managed by Mechanical and Pharmacological Thrombolysis. Neurocrit Care 11, 255–260 (2009). https://doi.org/10.1007/s12028-008-9159-7

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