Blunt traumatic vertebral artery injury [Neurosurgery Wiki]

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=====Blunt traumatic vertebral artery injury=====
[[Vertebral artery injury]] can be spontaneous or traumatic. 

Blunt [[traumatic vertebral artery injury]] is a type of [[blunt cerebrovascular injury]].

[[Traumatic vertebral artery injury]] (TVAI) presents a clinical challenge since it is hard to detect, has a diverse presentation and there are no widely accepted guidelines on diagnosis and management. Most evidence available on TVAI is class 3, based on case series from individual institutions. Spontaneous vertebral artery dissection is well described and typically managed by anticoagulation 
((Kim YK, Schulman S. Cervical artery dissection: pathology, epidemiology and
management. Thromb Res. 2009 Apr;123(6):810-21. doi:
10.1016/j.thromres.2009.01.013. Epub 2009 Mar 9. Review. PubMed PMID: 19269682.
)).

Blunt TVAI tends to occur where vessels are exposed to shearing forces, principally at junctions between fixed and mobile segments. The [[vertebral artery]] V2 segment is the most commonly affected in adult TVAI
((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 (Phila Pa 1976). 2005 Sep 1;30(17):1955-62.
PubMed PMID: 16135985.))
((Herrera DA, Vargas SA, Dublin AB. Endovascular treatment of traumatic injuries
of the vertebral artery. AJNR Am J Neuroradiol. 2008 Sep;29(8):1585-9. doi:
10.3174/ajnr.A1123. Epub 2008 May 22. PubMed PMID: 18499790.
)).

In infants and children, the V3 and upper V2 segment are more commonly affected
((Wang H, Orbach DB. Traumatic dissecting aneurysm at the vertebrobasilar
junction in a 3-month-old infant: evaluation and treatment strategies. Case
report. J Neurosurg Pediatr. 2008 May;1(5):415-9. doi: 10.3171/PED/2008/1/5/415. 
PubMed PMID: 18447682.
))
((Hasan I, Wapnick S, Tenner MS, Couldwell W. Vertebral artery dissection in
children: a comprehensive review. Pediatr Neurosurg. 2002 Oct;37(4):168-77.
Review. PubMed PMID: 12372909.
)).

====Diagnosis====
There is still debate regarding the optimal screening criteria, diagnostic imaging modality and treatment methods. In 2012 the American College of Surgeons proposed criteria for investigating patients with suspected TVAI and subsequent treatment methods, caveated with the statement that evidence is limited and still evolving
((Shafafy R, Suresh S, Afolayan JO, Vaccaro AR, Panchmatia JR. Blunt vertebral
vascular injury in trauma patients: ATLS(®) recommendations and review of current
evidence. J Spine Surg. 2017 Jun;3(2):217-225. doi: 10.21037/jss.2017.05.10.
Review. PubMed PMID: 28744503; PubMed Central PMCID: PMC5506306.
)).
----
Following the introduction of a Diagnostic Imaging Pathway in Department of Health of Western Australia reports a significant increase in the diagnosis of Blunt Carotid Artery and Vertebral Artery Injury (BCVI) in 2007. The previously low incidence of BCVI compared with other centres' reports indicated possible previous under-screening and diagnosis of this injury
((Sinnathamby M, Rao SV, Weber DG. Increased detection of blunt carotid and
vertebral artery injury after implementation of diagnostic imaging pathway in
level 1 trauma centre in Western Australia. Injury. 2017 Jun 13. pii:
S0020-1383(17)30370-4. doi: 10.1016/j.injury.2017.06.006. [Epub ahead of print]
PubMed PMID: 28647095.
)).

----
[[MRA]] has a moderate diagnostic accuracy in the diagnosis of blunt vertebral artery injuries. Further studies on high-field magnetic resonance scanners are recommended
((Karagiorgas GP, Brotis AG, Giannis T, Rountas CD, Vassiou KG, Fountas KN,
Kapsalaki EZ. The diagnostic accuracy of magnetic resonance angiography for blunt
vertebral artery injury detection in trauma patients: A systematic review and
meta-analysis. Clin Neurol Neurosurg. 2017 Jul 21;160:152-163. doi:
10.1016/j.clineuro.2017.07.005. [Epub ahead of print] Review. PubMed PMID:
28759887.
)).
----
Grading of Blunt traumatic cerebrovascular injury (TCVI) with [[CTA]] using the [[Biffl Scale]] is reliable
((Foreman PM, Griessenauer CJ, Kicielinski KP, Schmalz PGR, Rocque BG, Fusco MR,
Sullivan JC 3rd, Deveikis JP, Harrigan MR. Reliability assessment of the Biffl
Scale for blunt traumatic cerebrovascular injury as detected on computer
tomography angiography. J Neurosurg. 2017 Jul;127(1):32-35. doi:
10.3171/2016.7.JNS16849. Epub 2016 Oct 21. PubMed PMID: 27767400; PubMed Central 
PMCID: PMC5446307.
)).

====Case reports====
Weber et al. report the life- and limb-saving management in a 57-year-old hemodynamically unstable trauma patient. The individual developed hemorrhagic shock, and other major complications, including cortical blindness, related to a posterior circulation stroke. Full recovery was achieved by immediate endovascular prosthesis for subclavian artery (SA) rupture and stenting of a traumatic vertebral artery occlusion. Endovascular and alternative treatment options are discussed and the management of subsequent sequelae associated with aggressive anticoagulation in trauma patients is reviewed, including intracranial, abdominal and other sites of secondary hemorrhage
((Weber CD, Kobbe P, Herren C, Mahnken AH, Hildebrand F, Pape HC. Endovascular
Management of a Combined Subclavian and Vertebral Artery Injury in an Unstable
Polytrauma Patient: Case Report and Literature Review. Bull Emerg Trauma. 2017
Jan;5(1):53-57. PubMed PMID: 28246625; PubMed Central PMCID: PMC5316138.
)).
----
A 72-year-old woman was found at the bottom of the stairs by her family. She was immediately transferred to our hospital. She was, in spite of being in a state of shock, alert and oriented with normal respiration. A curvilinear laceration at the right suboccipital region was noticed. On neurological examination, she was diagnosed as having tetraparesis. Roentgenograms confirmed fractures of a vertebral body at C 6 and a transverse process at C 7. Head CT scan demonstrated a small low density area in the left putaminal region with cortical atrophy. As subcutaneous swelling of the left lower cervical portion was gradually taking place, vertebral arteriography was performed. Through left vertebral arteriography, extravasation of the contrast medium was demonstrated at the C6-7 level. Eighteen hours after admission, direct operation on the torn vessel was carried out through a supraclavicular linear skin incision. On operation, there was active bleeding from the lacerated vertebral artery at its point of entrance into the foramen transversarium. The bleeding point of the vertebral artery was trapped at the C 6 level. Postoperatively, the symptoms of the tetraparesis were improving. Two days after the operation, she had some food by herself. Suddenly, she had cardiac arrest five days after admission, and soon expired. It was 13 days since she had been admitted. Traumatic tear of a vertebral artery is very rare. Fourteen cases of intra-and extracranial vertebral artery rupture in closed head injury have been reported in previous writings
((Okuyama T, Niwa J, Shimizu K, Hirai H, Kubota T. [Traumatic rupture of the
vertebral artery associated with fracture of the cervical spine: a case report]. 
No Shinkei Geka. 1989 Oct;17(10):973-7. Japanese. PubMed PMID: 2812260.
)).