The forensic and clinicopathological spectrum of the vertebral artery

We report the forensic and clinicopathological spectrum of 14 postmortem cases involving the vertebral artery. In all cases, there was either pontocerebellar infarction (n = 8) or subarachnoid hemorrhage (n = 6). The underlying pathology of the vertebral artery was segmental mediolytic arteriopathy (n = 5), traumatic rupture of the arterial wall (n = 3), arterial dissection (n = 2), or atherosclerosis (n = 4). Histopathologic changes were often present in both the intracranial and extracranial segments of the vertebral artery. In our case series, the most frequent disease in the vertebral artery was segmental mediolytic arteriopathy which sometimes simultaneously involved the superior mesenteric artery. Our data show that a heterogeneous combination of acquired and genetic cofactors likely played a role in etiopathogenesis. The two main cofactors included sudden neck movements from applied external force (7/14 case, 50 %), and genetics (3/14 case, 21 %). Mutations in structural or regulatory genes of the arterial wall appear to be key risk factors and may interact with trauma or neck motion to result in fatal outcomes. We recommend that the autopsy of all cases with suspected vertebral artery lesions include histologic examination of both the intracranial and extracranial segments of the vertebral artery, histologic sampling of the intra-abdominal (mesenteric) arteries, and genetic testing. This will help clarify the role of injury, genetics, and disease when determining the cause of death in these complex cases.