PMC3256991_01
CT non-contrast of the cervical spine. a). Fracture of the right transverse process of C2 involving the transverse foramen. b). Similar fracture passing through right transverse foramen of C3.
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F1
Imaging revealed non-displaced fractures of the transverse processes on the right side of the second, third, fourth and seventh cervical vertebrae (C2, C3, C4 and C7) extending into the foramen transver-sarium (Fig.1). Interestingly, our patient described above, who was not screened for BCVI, did not have any of the classical risk factors for carotid injury (base of skull fracture, diffuse axonal injury, Le Fort 2 or 3 fracture) but did have a risk factor for vertebral artery injury (fractures passing through the transverse foramen, Fig. (1)) and therefore would have fit screening criteria for BCVI.
CT angiogram oblique view. Grade 2 injury of the left carotid artery with severe narrowing of the lumen proximal to the skull base. There was only a trickle of flow visualized in the petrous and cavernous segments distal to this lesion.
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F2
On the left side the distal cervical internal carotid artery was found to be nearly occluded (Fig.2) with only a string sign in the carotid canal, with patency of the distal left intracranial internal carotid artery and middle cerebral artery.
CT angiogram oblique view. Grade 2 injury of the right carotid artery proximal to the skull base with raised intimal flap.
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F3
On the right side, a raised intimal flap with early signs of pseudoaneurysm formation was seen with >50% narrowing of the lumen of the vessel (Fig. 3).
MRI of the brain with region of restricted diffusion consistent with infarct in the territory of the left middle cerebral artery.
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F4
Magnetic Resonance Imaging (MRI) of the brain confirmed a large left middle cerebral artery territory infarct (Fig. 4).
CT angiogram oblique view, at 3 month follow-up. Significant healing of the left carotid injury. There was normal flow visualized distal to the injury.
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F5
A repeat CT angiogram at 3 months revealed significant healing of the dissection on the left side to <50% (Fig. 5) while on the right side there was progression of the pseudoaneurysm to 18mm in length (Fig. 6).
PMC3256991_02