Trends in the management of traumatic vertebral artery injuries

doi:10.1016/0002-9610(89)90355-3

The American Journal of Surgery

Volume 158, Issue 2, August 1989, Pages 101-106

https://doi.org/10.1016/0002-9610(89)90355-3 Get rights and content

Abstract

From 1975 to 1988, 25 patients with a vertebral artery (VA) injury were treated. Admission neurologic status was intact in 14 patients (56 percent). Eight patients had deficits due to direct nerve or spinal cord injury, two patients had symptoms referable to vertebrobasilar ischemia, and one patient had a contralateral deficit due to an associated carotid artery injury. Twenty-two of 25 patients (88 percent) underwent diagnostic arteriography. Twelve patients (48 percent) with 9 occlusive and 3 minimal injuries were observed. Seven patients (28 percent), three with exsanguinating hemorrhage, were treated by operative exploration and VA ligation. Six patients (24 percent), two with a VA pseudoaneurysm and four with an arteriovenous fistula, were managed by percutaneous transcatheter embolization. The neurologic status was unchanged or unproved in 22 patients (88 percent) at discharge. Two patients developed Horner's syndrome after VA ligation. Transient posterior circulation ischemia occurred in a single patient after percutaneous transcatheter embolization. There was no mortality. The majority of VA injuries are best managed by nonoperative methods. Untoward neurologic sequelae are rare. Operative intervention and VA ligation should be reserved for patients with active hemorrhage or large pseudoaneurysms and arteriovenous fistulas which cannot be embolized.

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In our case, the goal of treatment of the EVAA was to repair the saccular aneurysm while preserving the VA patency for the intracranial blood supply. Owing to the tortuosity of the V1-V2 segment of the contralateral VA, we decided against sacrifice of the left VA by ligation, isolation, or endovascular occlusion, which might induce neurologic complications, reported to be as high as 8%.11 In view of the tortuous contralateral VA, we preferred to maintain the vascular patency of the diseased side and reduce unnecessary surgical iatrogenic injury.
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Penetrating vertebral artery injuries (VAIs) are rare. Because of their rarity, complex anatomy, and difficult surgical exposures, few surgeons and trauma centers have developed significant experience with their management. The objectives of this study were to review their incidence, clinical presentation, radiologic identification, management, complications, and outcomes and to provide a review of anatomic exposures and surgical techniques for their management.
A literature search on MEDLINE Complete-PubMed, Cochrane, Ovid, and Embase for the period of 1893 to 2018 was conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Our literature search yielded a total of 181 potentially eligible articles with 71 confirmed articles, consisting of 21 penetrating neck injury series, 13 VAI-specific series, and 37 case reports. Operative procedures and outcomes were recorded along with methods of angiographic imaging and operative management. All articles were reviewed by at least two independent authors, and data were analyzed collectively.
There were a total of 462 patients with penetrating VAIs. The incidence of VAI in the civilian population was 3.1% vs 0.3% in the military population. More complete data were available from 13 collected VAI-specific series and 37 case reports for a total of 362 patients. Mechanism of injury data were available for 341 patients (94.2%). There were gunshot wounds (178 patients [49.2%]), stab wounds (131 [73.6%]), and miscellaneous mechanisms of injury (32 [8.8%]). Anatomic site of injury data were available for 177 (49%) patients: 92 (25.4%) left, 84 (23.2%) right, and 1 (0.3%) bilateral. Anatomic segment of injury data were available for 204 patients (56.4%): 28 (7.7%) V1, 125 (34.5%) V2, and 51 (14.1%) V3. Treatment data were available for 212 patients. Computed tomography angiography was the most common imaging modality (163 patients [77%]). Injuries were addressed by operative management (94 [44.3%]), angiography and angioembolization (72 [34%]), combined approaches (11 [5.2%]), and observation (58 [27.4%]). Stenting and repair were less frequently employed (10 [4.7%]). The incidence of aneurysms or pseudoaneurysms was 18.5% (67); the incidence of arteriovenous fistula was 16.9% (61). The calculated mortality in VAI-specific series was 15.1%; in the individual case report group, it was 10.5%.
The majority of VAIs present without neurologic symptoms, although some may present with exsanguinating hemorrhage. Computed tomography angiography should be considered first line to establish diagnosis. Gunshot wounds account for most injuries. The most frequently injured segment is V2. Surgical ligation is the most common intervention, followed by angioembolization, both of which constitute important management approaches.
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Aneurysms of the extracranial vertebral artery are uncommon, with most cases attributed to penetrating head and neck trauma. We report a 29-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. This patient's aneurysm was definitively treated after a successful balloon occlusion test of his affected vertebral artery. An endovascular approach was used combining coil embolization of the distal vertebral artery and a covered stent graft in the subclavian. Although aneurysms of this size and location are traditionally repaired with open aneurysmectomy, we show that endovascular approaches can be a safe and effective alternative.
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Controversy persists in the literature as to whether proximal ligation alone is adequate; some believe that proximal and distal ligation must be done to avert distal thrombus propagation. Most agree that the risk of this complication is reduced by prophylactic heparinization in the acute phase for any patient who has undergone vertebral artery ligation.86 The surgical and endovascular procedures described earlier involve the occlusion of the arterial lumen, which is the main disadvantage of these methods.
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^☆: Presented at the 17th Annual Meeting of the Society for Clinical Vascular Surgery, Boca Raton, Florida, March 29–April 1, 1989.

¹: From the Department of Surgery, University of Southern California School of Medicine and the Los Angeles County-University of Southern California Medical Center, Los Angeles, California.

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Scientific paperTrends in the management of traumatic vertebral artery injuries☆

Abstract

Am J Surg

Am J Surg

Forty-three cases of vertebral artery trauma

J Trauma

Traumatisms and traumatic aneurysms of the vertebral artery and their surgical treatment, with the report of a cured case

Ann Surg

Vertebral artery trauma: acute recognition and treatment

Arch Surg

Vertebral artery embolization for control of massive hemorrhage

AJNR

Vertebral artery transection from blunt trauma treated by embolization

J Trauma

Percutaneous transluminal embolization of vertebral artery injury

Aust N Z J Surg

Scientific paper
Trends in the management of traumatic vertebral artery injuries☆