Clinical and radiological outcomes following traumatic Grade 3 and 4 vertebral artery injuries: a 10-year retrospective analysis from a Level I trauma center. The Parkland Carotid and Vertebral Artery Injury Survey

Abstract

ObJect Grade 3 and 4 blunt vertebral artery (VA) injuries may carry a different natural course from that of lower-grade blunt VA injuries. Proper screening, management, and follow-up of these injuries remain controversial. Grade 3 and 4 blunt VA injuries were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. MetHODS A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries from August 2003 to April 2013 was performed, and Grade 3 and 4 blunt VA injuries were identified. Grade 3 injuries were defined as stenosis of the vessel greater than 50% or the development of a pseudoaneurysm, and Grade 4 injuries were defined as complete vessel occlusion. Demographic information, radiographic imaging findings, number of imaging sessions performed per individual, length of radiographic follow-up, radiographic outcome at end of follow-up, treatment(s) provided, and documentation of ischemic stroke or transient ischemic attack were recorded. reSultS A total of 79 high-grade (Grade 3 and 4) blunt VA injuries in 67 patients were identified. Fifty-nine patients with 66 high-grade blunt VA injuries were available for follow-up. There were 17 patients with 23 Grade 3 injuries and 42 patients with 43 Grade 4 injuries. The mean follow-up duration was 58 days for Grade 3 and 67 days for Grade 4 blunt VA injuries. Repeat imaging of Grade 3 blunt VA injuries showed that 39% of injuries were radiographically stable, 43% resolved, and 13% improved, while 1 injury radiographically worsened. Repeat imaging of the Grade 4 blunt VA injuries showed that 65% of injuries were radiographically stable (persistent occlusion), 30% improved (recanalization of the vessel), and in 2 cases (5%) the injury resolved. All Grade 3 injuries that were treated were managed with aspirin or clopidogrel alone, as were the majority of Grade 4 injuries. There were 3 cerebral infarctions thought to be related to Grade 4 blunt VA injuries, which were likely present on admission. All 3 of these patients died at a mean of 13.7 days after hospital admission. No cerebral infarctions directly related to Grade 3 blunt VA injuries were identified. cONcluSiONS The majority of high-grade blunt VA injuries remain stable or are improved at final follow-up. Despite a 4% rate of radiographic worsening in the Grade 3 blunt VA injury group and a 35% recanalization rate in the Grade 4 blunt VA injury group, there were no adverse clinical outcomes associated with these radiographic changes. No cerebral infarctions were noted in the Grade 3 group. A 7% stroke rate was identified in the Grade 4 blunt VA injury group; however, this was confined to the immediate postinjury period and was associated with 100% mortality. While these data suggest that these high-grade vertebral artery injuries may require less intensive radiographic follow-up, future prospective studies are needed to make conclusive changes related to treatment and management....

Corrective spinal surgery may be protective against stroke in patients with blunt traumatic vertebral artery occlusion

“…5,8,10,13 While some reports have marginalized the clinical consequences of these strokes, often identifying asymptomatic or functionally insignificant areas of ischemia, 10,15 others have described significant morbidity and mortality. 12 Our series supports the latter with 7 of 10 strokes being symptomatic, including 2 deaths directly attributable to vertebrobasilar ischemia.…”

“…10 Scott et al reported a stroke rate of 7.1% but hypothesized that the cerebral infarcts occurred in the immediate postinjury period and thus were present on admission. 12 The current series also failed to identify a significant difference in the use of antiplatelets between patients with and without stroke. Future investigation should focus on novel therapies for the management of traumatically occluded VAs; possibilities include dual antiplatelet therapy, systemic anticoagulation, and endovascular intervention.…”

“…This rate is comparable to previous studies reporting a range of 7.1%-33.3%. 1,10,12,14 It is important to note that despite the robust collateral circulation of the posterior fossa, patients with traumatic VA occlusion are at high risk for ischemic stroke. While hemodynamic failure is a plausible etiology in bilateral VA occlusion (50% stroke rate in this and a previously reported series 10 ), and in patients with thrombosis of the dominant VA, thromboembolism appears as the likely culprit in the majority of patients.…”

“…The incidence of ischemic stroke in this setting ranges from 7.1% to 33.3%. 1,10,12,14 Anecdotal evidence suggests that cervical spine manipulation (i.e., closed reduction, surgery) in the presence of a traumatic VA occlusion increases the risk of embolization and ischemic stroke. However, some authors believe that surgical fixation of the cervical spine decompresses the injured vessel and may avoid thrombus propagation, thereby reducing the risk of ischemic stroke.…”

Blunt vertebral vascular injury in trauma patients: ATLS® recommendations and review of current evidence

“…TVAI is a potentially devastating injury. First described by Matas in 1893 (1), TVAI often affects the young following road traffic accidents, hanging and sporting injuries and the mortality rate may be as high as 100% (2). Despite this, TVAI is notoriously difficult to diagnose (3).…”